pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_d_opt_use_mand_16b_yn	pbp_d_opt_use_mand_16b1_yn	pbp_d_opt_use_mand_16b2_yn	pbp_d_opt_use_mand_16b3_yn	pbp_d_opt_use_mand_16b4_yn	pbp_d_opt_use_mand_16b5_yn	pbp_d_opt_use_mand_16b6_yn	pbp_d_opt_use_mand_16c_yn	pbp_d_opt_use_mand_16c1_yn	pbp_d_opt_use_mand_16c2_yn	pbp_d_opt_use_mand_16c3_yn	pbp_d_opt_use_mand_16c4_yn	pbp_d_opt_use_mand_16c5_yn	pbp_d_opt_use_mand_16c6_yn	pbp_d_opt_use_mand_16c7_yn	pbp_d_opt_use_mand_16c8_yn	pbp_d_opt_use_mand_16c9_yn	pbp_d_opt_use_mand_16c10_yn	pbp_b16b_maxplan_pv_yn	pbp_b16b_maxplan_pv_in_oon	pbp_b16b_maxplan_pv_amt	pbp_b16b_maxplan_pv_per	pbp_b16b_maxplan_pv_per_desc	pbp_b16b_maxenr_pv_yn	pbp_b16b_maxenr_pv_amt	pbp_b16b_maxenr_pv_per	pbp_b16b_maxenr_pv_per_desc	pbp_b16b_coins_ov_yn	pbp_b16b_coins_ov_svcs	pbp_b16b_coins_ov_pct	pbp_b16b_coins_ov_pct_min	pbp_b16b_coins_ov_pct_max	pbp_b16b_copay_ov_yn	pbp_b16b_copay_ov_svcs	pbp_b16b_copay_ov_amt	pbp_b16b_copay_ov_amt_min	pbp_b16b_copay_ov_amt_max	pbp_b16b_ded_pv_yn	pbp_b16b_ded_pv_amt	pbp_b16b_bendesc_oe_amo	pbp_b16b_bendesc_oe_lim	pbp_b16b_bendesc_oe_num	pbp_b16b_bendesc_oe_per	pbp_b16b_bendesc_oe_desc	pbp_b16b_coins_oe_yn	pbp_b16b_coins_oe_pct	pbp_b16b_coins_oe_pct_min	pbp_b16b_coins_oe_pct_max	pbp_b16b_copay_oe_yn	pbp_b16b_copay_oe_amt	pbp_b16b_copay_oe_amt_min	pbp_b16b_copay_oe_amt_max	pbp_b16b_auth_oe_yn	pbp_b16b_refer_oe_yn	pbp_b16b_bendesc_dx_amo	pbp_b16b_bendesc_dx_lim	pbp_b16b_bendesc_dx_num	pbp_b16b_bendesc_dx_per	pbp_b16b_bendesc_dx_desc	pbp_b16b_coins_dx_yn	pbp_b16b_coins_dx_pct	pbp_b16b_coins_dx_pct_min	pbp_b16b_coins_dx_pct_max	pbp_b16b_copay_dx_yn	pbp_b16b_copay_dx_amt	pbp_b16b_copay_dx_amt_min	pbp_b16b_copay_dx_amt_max	pbp_b16b_auth_dx_yn	pbp_b16b_refer_dx_yn	pbp_b16b_bendesc_ods_amo	pbp_b16b_bendesc_ods_lim	pbp_b16b_bendesc_ods_num	pbp_b16b_bendesc_ods_per	pbp_b16b_bendesc_ods_desc	pbp_b16b_coins_ods_yn	pbp_b16b_coins_ods_pct	pbp_b16b_coins_ods_pct_min	pbp_b16b_coins_ods_pct_max	pbp_b16b_copay_ods_yn	pbp_b16b_copay_ods_amt	pbp_b16b_copay_ods_amt_min	pbp_b16b_copay_ods_amt_max	pbp_b16b_auth_ods_yn	pbp_b16b_refer_ods_yn	pbp_b16b_bendesc_pc_amo	pbp_b16b_bendesc_pc_lim	pbp_b16b_bendesc_pc_num	pbp_b16b_bendesc_pc_per	pbp_b16b_bendesc_pc_desc	pbp_b16b_coins_pc_yn	pbp_b16b_coins_pc_pct	pbp_b16b_coins_pc_pct_min	pbp_b16b_coins_pc_pct_max	pbp_b16b_copay_pc_yn	pbp_b16b_copay_pc_amt	pbp_b16b_copay_pc_amt_min	pbp_b16b_copay_pc_amt_max	pbp_b16b_auth_pc_yn	pbp_b16b_refer_pc_yn	pbp_b16b_bendesc_ft_amo	pbp_b16b_bendesc_ft_lim	pbp_b16b_bendesc_ft_num	pbp_b16b_bendesc_ft_per	pbp_b16b_bendesc_ft_desc	pbp_b16b_coins_ft_yn	pbp_b16b_coins_ft_pct	pbp_b16b_coins_ft_pct_min	pbp_b16b_coins_ft_pct_max	pbp_b16b_copay_ft_yn	pbp_b16b_copay_ft_amt	pbp_b16b_copay_ft_amt_min	pbp_b16b_copay_ft_amt_max	pbp_b16b_auth_ft_yn	pbp_b16b_refer_ft_yn	pbp_b16b_bendesc_ops_amo	pbp_b16b_bendesc_ops_lim	pbp_b16b_bendesc_ops_num	pbp_b16b_bendesc_ops_per	pbp_b16b_bendesc_ops_desc	pbp_b16b_coins_ops_yn	pbp_b16b_coins_ops_pct	pbp_b16b_coins_ops_pct_min	pbp_b16b_coins_ops_pct_max	pbp_b16b_copay_ops_yn	pbp_b16b_copay_ops_amt	pbp_b16b_copay_ops_amt_min	pbp_b16b_copay_ops_amt_max	pbp_b16b_auth_ops_yn	pbp_b16b_refer_ops_yn	pbp_b16c_maxplan_cmp_yn	pbp_b16c_maxplan_cmp_type	pbp_b16c_maxplan_cmp_in_oon	pbp_b16c_maxplan_cmp_amt	pbp_b16c_maxplan_cmp_per	pbp_b16c_maxplan_cmp_per_desc	pbp_b16c_maxenr_cmp_yn	pbp_b16c_maxenr_cmp_type	pbp_b16c_maxenr_cmp_amt	pbp_b16c_maxenr_cmp_per	pbp_b16c_maxenr_cmp_per_desc	pbp_b16c_ded_cmp_yn	pbp_b16c_ded_cmp_amt	pbp_b16c_bendesc_rs_amo	pbp_b16c_bendesc_rs_lim	pbp_b16c_bendesc_rs_num	pbp_b16c_bendesc_rs_per	pbp_b16c_bendesc_rs_desc	pbp_b16c_coins_rs_yn	pbp_b16c_coins_rs_pct	pbp_b16c_coins_rs_pct_min	pbp_b16c_coins_rs_pct_max	pbp_b16c_copay_rs_yn	pbp_b16c_copay_rs_amt	pbp_b16c_copay_rs_amt_min	pbp_b16c_copay_rs_amt_max	pbp_b16c_auth_rs_yn	pbp_b16c_refer_rs_yn	pbp_b16c_bendesc_end_amo	pbp_b16c_bendesc_end_lim	pbp_b16c_bendesc_end_num	pbp_b16c_bendesc_end_per	pbp_b16c_bendesc_end_desc	pbp_b16c_coins_end_yn	pbp_b16c_coins_end_pct	pbp_b16c_coins_end_pct_min	pbp_b16c_coins_end_pct_max	pbp_b16c_copay_end_yn	pbp_b16c_copay_end_amt	pbp_b16c_copay_end_amt_min	pbp_b16c_copay_end_amt_max	pbp_b16c_auth_end_yn	pbp_b16c_refer_end_yn	pbp_b16c_bendesc_peri_amo	pbp_b16c_bendesc_peri_lim	pbp_b16c_bendesc_peri_num	pbp_b16c_bendesc_peri_per	pbp_b16c_bendesc_peri_desc	pbp_b16c_coins_peri_yn	pbp_b16c_coins_peri_pct	pbp_b16c_coins_peri_pct_min	pbp_b16c_coins_peri_pct_max	pbp_b16c_copay_peri_yn	pbp_b16c_copay_peri_amt	pbp_b16c_copay_peri_amt_min	pbp_b16c_copay_peri_amt_max	pbp_b16c_auth_peri_yn	pbp_b16c_refer_peri_yn	pbp_b16c_bendesc_prm_amo	pbp_b16c_bendesc_prm_lim	pbp_b16c_bendesc_prm_num	pbp_b16c_bendesc_prm_per	pbp_b16c_bendesc_prm_desc	pbp_b16c_coins_prm_yn	pbp_b16c_coins_prm_pct	pbp_b16c_coins_prm_pct_min	pbp_b16c_coins_prm_pct_max	pbp_b16c_copay_prm_yn	pbp_b16c_copay_prm_amt	pbp_b16c_copay_prm_amt_min	pbp_b16c_copay_prm_amt_max	pbp_b16c_auth_prm_yn	pbp_b16c_refer_prm_yn	pbp_b16c_bendesc_mxpr_amo	pbp_b16c_bendesc_mxpr_lim	pbp_b16c_bendesc_mxpr_num	pbp_b16c_bendesc_mxpr_per	pbp_b16c_bendesc_mxpr_desc	pbp_b16c_coins_mxpr_yn	pbp_b16c_coins_mxpr_pct	pbp_b16c_coins_mxpr_pct_min	pbp_b16c_coins_mxpr_pct_max	pbp_b16c_copay_mxpr_yn	pbp_b16c_copay_mxpr_amt	pbp_b16c_copay_mxpr_amt_min	pbp_b16c_copay_mxpr_amt_max	pbp_b16c_auth_mxpr_yn	pbp_b16c_refer_mxpr_yn	pbp_b16c_bendesc_impl_amo	pbp_b16c_bendesc_impl_lim	pbp_b16c_bendesc_impl_num	pbp_b16c_bendesc_impl_per	pbp_b16c_bendesc_impl_desc	pbp_b16c_coins_impl_yn	pbp_b16c_coins_impl_pct	pbp_b16c_coins_impl_pct_min	pbp_b16c_coins_impl_pct_max	pbp_b16c_copay_impl_yn	pbp_b16c_copay_impl_amt	pbp_b16c_copay_impl_amt_min	pbp_b16c_copay_impl_amt_max	pbp_b16c_auth_impl_yn	pbp_b16c_refer_impl_yn	pbp_b16c_bendesc_prf_amo	pbp_b16c_bendesc_prf_lim	pbp_b16c_bendesc_prf_num	pbp_b16c_bendesc_prf_per	pbp_b16c_bendesc_prf_desc	pbp_b16c_coins_prf_yn	pbp_b16c_coins_prf_pct	pbp_b16c_coins_prf_pct_min	pbp_b16c_coins_prf_pct_max	pbp_b16c_copay_prf_yn	pbp_b16c_copay_prf_amt	pbp_b16c_copay_prf_amt_min	pbp_b16c_copay_prf_amt_max	pbp_b16c_auth_prf_yn	pbp_b16c_refer_prf_yn	pbp_b16c_bendesc_omsg_amo	pbp_b16c_bendesc_omsg_lim	pbp_b16c_bendesc_omsg_num	pbp_b16c_bendesc_omsg_per	pbp_b16c_bendesc_omsg_desc	pbp_b16c_coins_omsg_yn	pbp_b16c_coins_omsg_pct	pbp_b16c_coins_omsg_pct_min	pbp_b16c_coins_omsg_pct_max	pbp_b16c_copay_omsg_yn	pbp_b16c_copay_omsg_amt	pbp_b16c_copay_omsg_amt_min	pbp_b16c_copay_omsg_amt_max	pbp_b16c_auth_omsg_yn	pbp_b16c_refer_omsg_yn	pbp_b16c_bendesc_orth_amo	pbp_b16c_bendesc_orth_lim	pbp_b16c_bendesc_orth_num	pbp_b16c_bendesc_orth_per	pbp_b16c_bendesc_orth_desc	pbp_b16c_coins_orth_yn	pbp_b16c_coins_orth_pct	pbp_b16c_coins_orth_pct_min	pbp_b16c_coins_orth_pct_max	pbp_b16c_copay_orth_yn	pbp_b16c_copay_orth_amt	pbp_b16c_copay_orth_amt_min	pbp_b16c_copay_orth_amt_max	pbp_b16c_auth_orth_yn	pbp_b16c_refer_orth_yn	pbp_b16c_bendesc_ags_amo	pbp_b16c_bendesc_ags_lim	pbp_b16c_bendesc_ags_num	pbp_b16c_bendesc_ags_per	pbp_b16c_bendesc_ags_desc	pbp_b16c_coins_ags_yn	pbp_b16c_coins_ags_pct	pbp_b16c_coins_ags_pct_min	pbp_b16c_coins_ags_pct_max	pbp_b16c_copay_ags_yn	pbp_b16c_copay_ags_amt	pbp_b16c_copay_ags_amt_min	pbp_b16c_copay_ags_amt_max	pbp_b16c_auth_ags_yn	pbp_b16c_refer_ags_yn	pbp_d_opt_identifier
H0107	003	0	1	04	01	H0107_003_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H0107	004	0	1	04	01	H0107_004_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H0107	005	0	1	04	01	H0107_005_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H0107	011	0	1	04	01	H0107_011_0	5								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H0294	002	0	1	04	01	H0294_002_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	004	0	1	04	01	H0294_004_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	012	0	1	04	01	H0294_012_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	014	0	1	04	01	H0294_014_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	015	0	1	04	01	H0294_015_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	016	0	1	04	01	H0294_016_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	023	0	1	04	01	H0294_023_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	026	0	1	04	01	H0294_026_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	032	0	1	04	01	H0294_032_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	037	0	1	04	01	H0294_037_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	038	0	1	04	01	H0294_038_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	039	0	1	04	01	H0294_039_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0294	047	0	1	04	01	H0294_047_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0332	001	0	1	01	01	H0332_001_0	7								2	2							2																																																																																																																		2						2					2		3	2	1	6	One per tooth every 60 months	1	50	50	50	2				2	2	3	2	1	6	1 per tooth every 60 months	1	50	50	50	2				2	2	3	2	1	6	Varying periodicity per code.D4210, D4211, D4260, D4261, D4341, D4342 - 4 QUAD/36 MONTHS.D4240, D4355 - 1 PER TOOTH/12 MONTHS, D4910 1/6 MONTHS.ALL OTHER CODES 1/60 MONTHS.	1	50	50	50	2				2	2	3	2	1	6	Once every 60 months	1	50	50	50	2				2	2																3	2	1	6	D6110-6111 and D6194, once every 60 months. All other covered codes once every 120 months.	1	50	50	50	2				2	2	3	2	1	6	Once every 60 months	1	50	50	50	2				2	2	3	2	1	6	Varying periodicity per code.D7310, D7311, D7320,  D7321, D7340 and D7350 - 4 QUAD PER LIFETIME.ALL OTHER CODES 1 PER TOOTH PER LIFETIME	1	50	50	50	2				2	2																															001
H0432	003	0	1	02	01	H0432_003_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0504	015	0	1	01	01	H0504_015_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	015	0	1	01	01	H0504_015_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	017	0	1	01	01	H0504_017_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	017	0	1	01	01	H0504_017_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	021	0	1	01	01	H0504_021_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	021	0	1	01	01	H0504_021_0	8	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	026	0	1	01	01	H0504_026_0	7																			2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	026	0	1	01	01	H0504_026_0	7																			2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	028	0	1	01	01	H0504_028_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	028	0	1	01	01	H0504_028_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	038	0	1	01	01	H0504_038_0	7																			2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	038	0	1	01	01	H0504_038_0	7																			2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	039	0	1	01	01	H0504_039_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	001
H0504	040	0	1	01	01	H0504_040_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	040	0	1	01	01	H0504_040_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	041	0	1	01	01	H0504_041_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	041	0	1	01	01	H0504_041_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	043	0	1	01	01	H0504_043_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	043	0	1	01	01	H0504_043_0	7	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0504	047	0	1	01	01	H0504_047_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	047	0	1	01	01	H0504_047_0	7	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	3		20	30	2				2	2	002
H0524	003	0	1	01	01	H0524_003_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	008	0	1	01	01	H0524_008_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	013	0	1	01	01	H0524_013_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	015	0	1	01	01	H0524_015_0	8	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	031	0	1	01	01	H0524_031_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	032	0	1	01	01	H0524_032_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	033	0	1	01	01	H0524_033_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	034	0	1	01	01	H0524_034_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	035	0	1	01	01	H0524_035_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	036	0	1	01	01	H0524_036_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	037	0	1	01	01	H0524_037_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	038	0	1	01	01	H0524_038_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	039	0	1	01	01	H0524_039_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	040	0	1	01	01	H0524_040_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	041	0	1	01	01	H0524_041_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	042	0	1	01	01	H0524_042_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	043	0	1	01	01	H0524_043_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	046	0	1	01	01	H0524_046_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	051	0	1	01	01	H0524_051_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	054	0	1	01	01	H0524_054_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	059	0	1	01	01	H0524_059_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	060	0	1	01	01	H0524_060_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	061	0	1	01	01	H0524_061_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	062	0	1	01	01	H0524_062_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	063	0	1	01	01	H0524_063_0	8	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	064	0	1	01	01	H0524_064_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	065	0	1	01	01	H0524_065_0	7	2	2	2	2	2		2	2			2					2			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	214.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	153.00	1	1	2						2					2		3	1				2				3		41.00	533.00	1	1	3	1				2				3		38.00	492.00	1	1	3	1				2				3		0.00	518.00	1	1	3	1				2				3		41.00	804.00	1	1																3	2	2	3		2				3		0.00	1585.00	1	1	3	1				2				3		70.00	543.00	1	1	3	1				2				3		0.00	1470.00	1	1																3	1				2				3		0.00	109.00	1	1	001
H0524	078	0	1	01	01	H0524_078_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	081	0	1	01	01	H0524_081_0	8	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	082	0	1	01	01	H0524_082_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0524	083	0	1	01	01	H0524_083_0	7	2	2	2	2	2		2	2	2		2					2		2	2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	1	1	3	2	1	6	Cone beam x-rays are covered once every 60 months.	2				3		0.00	155.00	1	1	3	1				2				1	0.00	0.00	0.00	1	1	3	2	1	3		2				1	0.00	0.00	0.00	1	1																3	1				2				3		0.00	78.00	1	1	2						2					2		3	1				2				3		7.00	317.00	1	1	3	1				2				3		25.00	398.00	1	1	3	1				2				3		0.00	412.00	1	1	3	1				2				3		23.00	458.00	1	1																3	2	2	3		2				3		0.00	1153.00	1	1	3	1				2				3		32.00	317.00	1	1	3	1				2				3		0.00	1070.00	1	1																3	1				2				3		0.00	88.00	1	1	001
H0543	013	0	1	02	01	H0543_013_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	035	0	1	02	01	H0543_035_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	036	0	1	02	01	H0543_036_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	086	0	1	02	01	H0543_086_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	121	0	1	02	01	H0543_121_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	140	0	1	02	01	H0543_140_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	145	0	1	02	01	H0543_145_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	146	0	1	02	01	H0543_146_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	147	0	1	02	01	H0543_147_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	152	0	1	02	01	H0543_152_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	167	0	1	02	01	H0543_167_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	188	0	1	02	01	H0543_188_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	189	0	1	02	01	H0543_189_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	196	0	1	02	01	H0543_196_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	204	0	1	02	01	H0543_204_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	214	0	1	02	01	H0543_214_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	222	0	1	02	01	H0543_222_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	223	0	1	02	01	H0543_223_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	224	0	1	02	01	H0543_224_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	225	0	1	02	01	H0543_225_0	10	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	228	0	1	02	01	H0543_228_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	232	0	1	02	01	H0543_232_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	234	0	1	02	01	H0543_234_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	236	0	1	02	01	H0543_236_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	237	0	1	02	01	H0543_237_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0543	238	0	1	02	01	H0543_238_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0544	002	0	1	02	01	H0544_002_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	002	0	1	02	01	H0544_002_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	002	0	1	02	01	H0544_002_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	004	0	1	02	01	H0544_004_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	004	0	1	02	01	H0544_004_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	004	0	1	02	01	H0544_004_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	005	0	1	01	01	H0544_005_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	005	0	1	01	01	H0544_005_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	005	0	1	01	01	H0544_005_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	007	0	1	02	01	H0544_007_0	6	2	2	2		2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	007	0	1	02	01	H0544_007_0	6	2	2	2		2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	007	0	1	02	01	H0544_007_0	6	2	2	2		2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	008	0	1	02	01	H0544_008_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	008	0	1	02	01	H0544_008_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	008	0	1	02	01	H0544_008_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	010	0	1	02	01	H0544_010_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	010	0	1	02	01	H0544_010_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	010	0	1	02	01	H0544_010_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	014	0	1	02	01	H0544_014_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	014	0	1	02	01	H0544_014_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	014	0	1	02	01	H0544_014_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	015	0	1	02	01	H0544_015_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	015	0	1	02	01	H0544_015_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	015	0	1	02	01	H0544_015_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	019	0	1	02	01	H0544_019_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	019	0	1	02	01	H0544_019_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	019	0	1	02	01	H0544_019_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	020	0	1	02	01	H0544_020_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	020	0	1	02	01	H0544_020_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	020	0	1	02	01	H0544_020_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	056	0	1	02	01	H0544_056_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	056	0	1	02	01	H0544_056_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	056	0	1	02	01	H0544_056_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	058	0	1	02	01	H0544_058_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	058	0	1	02	01	H0544_058_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	058	0	1	02	01	H0544_058_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	061	0	1	02	01	H0544_061_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	061	0	1	02	01	H0544_061_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	061	0	1	02	01	H0544_061_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	062	0	1	02	01	H0544_062_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	062	0	1	02	01	H0544_062_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	062	0	1	02	01	H0544_062_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	063	0	1	02	01	H0544_063_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	063	0	1	02	01	H0544_063_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	063	0	1	02	01	H0544_063_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	064	0	1	02	01	H0544_064_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	064	0	1	02	01	H0544_064_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	064	0	1	02	01	H0544_064_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	065	0	1	02	01	H0544_065_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	065	0	1	02	01	H0544_065_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	065	0	1	02	01	H0544_065_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	066	0	1	02	01	H0544_066_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	066	0	1	02	01	H0544_066_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	066	0	1	02	01	H0544_066_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	069	0	1	02	01	H0544_069_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	069	0	1	02	01	H0544_069_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	069	0	1	02	01	H0544_069_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	095	0	1	02	01	H0544_095_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	095	0	1	02	01	H0544_095_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	095	0	1	02	01	H0544_095_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	096	0	1	02	01	H0544_096_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	096	0	1	02	01	H0544_096_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	096	0	1	02	01	H0544_096_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	098	0	1	02	01	H0544_098_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	098	0	1	02	01	H0544_098_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	098	0	1	02	01	H0544_098_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	108	0	1	02	01	H0544_108_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	108	0	1	02	01	H0544_108_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	108	0	1	02	01	H0544_108_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0571	001	0	1	01	01	H0571_001_0	11	2			2															2					2														2																																3	1				2				1	0.00	0.00	0.00	2	2																																														2						2					2		3	1				2				3		15.00	375.00	2	2	3	1				2				3		12.00	275.00	2	2																3	2	1	3		2				3		0.00	375.00	2	2																																														3	1				2				3		30.00	150.00	2	2																															001
H0571	007	0	1	01	01	H0571_007_0	10	2	2	2	2	2			2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				1	35.00	35.00	35.00	2	2	3	2	2	3		2				2				2	2																															2						2					2		3	1				2				3		15.00	375.00	2	2	3	1				2				3		12.00	275.00	2	2	3	2	1	3		2				3		0.00	450.00	2	2	3	2	1	3		2				3		0.00	375.00	2	2																															3	2	1	3		2				3		0.00	375.00	2	2	3	2	1	3		2				3		0.00	375.00	2	2																															001
H0571	010	0	1	01	01	H0571_010_0	10	2			2															2					2														2																																3	1				2				1	0.00	0.00	0.00	2	2																																														2						2					2		3	1				2				3		15.00	375.00	2	2	3	1				2				3		12.00	275.00	2	2																3	2	1	3		2				3		0.00	375.00	2	2																																														3	1				2				3		30.00	150.00	2	2																															001
H0571	011	0	1	01	01	H0571_011_0	10	2	2	2	2	2			2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				1	35.00	35.00	35.00	2	2	3	2	2	3		2				2				2	2																															2						2					2		3	1				2				3		15.00	375.00	2	2	3	1				2				3		12.00	275.00	2	2	3	2	1	3		2				3		0.00	450.00	2	2	3	2	1	3		2				3		0.00	375.00	2	2																															3	2	1	3		2				3		0.00	375.00	2	2	3	2	1	3		2				3		0.00	375.00	2	2																															001
H0609	012	0	1	02	01	H0609_012_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	026	0	1	02	01	H0609_026_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	036	1	1	02	01	H0609_036_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	036	2	1	02	01	H0609_036_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	040	0	1	02	01	H0609_040_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	051	0	1	02	01	H0609_051_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	054	0	1	02	01	H0609_054_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	059	0	1	02	01	H0609_059_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	066	0	1	02	01	H0609_066_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	067	0	1	02	01	H0609_067_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	068	0	1	02	01	H0609_068_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0609	072	0	1	02	01	H0609_072_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0630	013	0	1	01	01	H0630_013_0	10								2	2	2	2			2																																																																																																																				1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	015	0	1	02	01	H0630_015_0	10								2	2	2	2	2	2	2	2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	016	0	1	02	01	H0630_016_0	10								2	2	2	2	2	2	2	2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	017	0	1	01	01	H0630_017_0	10								2	2	2	2			2																																																																																																																				1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	020	0	1	01	01	H0630_020_0	10								2	2	2	2			2																																																																																																																				1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	021	0	1	02	01	H0630_021_0	9								2	2	2	2	2	2	2	2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	023	0	1	02	01	H0630_023_0	9								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	025	0	1	02	01	H0630_025_0	9								2	2	2	2	2	2	2	2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	026	0	1	02	01	H0630_026_0	9								2	2	2	2	2	2	2	2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0755	030	0	1	02	01	H0755_030_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0755	031	0	1	02	01	H0755_031_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0755	032	0	1	02	01	H0755_032_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0755	033	0	1	02	01	H0755_033_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0755	038	0	1	02	01	H0755_038_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0755	044	0	1	02	01	H0755_044_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H0755	045	0	1	02	01	H0755_045_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1170	002	0	1	01	01	H1170_002_0	12	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	008	0	1	01	01	H1170_008_0	12	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	009	0	1	01	01	H1170_009_0	12	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	011	0	1	01	01	H1170_011_0	11	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	012	0	1	01	01	H1170_012_0	11	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	013	0	1	02	01	H1170_013_0	11	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	014	0	1	01	01	H1170_014_0	11	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1170	015	0	1	01	01	H1170_015_0	11	2		2					2	2		2	2				2		2	2					2														2																	3	2	1	6	X-rays are limited to cone beam CT.	1	75	75	75	3		71.00	94.00	1	1																																																													1	2		1600.00	3		2					2		3	1				1	75	75	75	3		0.00	580.00	1	1	3	1				1	75	75	75	3		18.00	308.00	1	1	3	1				1	75	75	75	3		0.00	400.00	1	1	3	1				2				3		18.00	500.00	1	1																3	2	1	6	Implant limitation of one placement, one abutment and one prosthetic per year.	2				3		33.00	1400.00	1	1	3	1				2				3		26.00	580.00	1	1	3	1				1	75	75	75	3		0.00	320.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	3	1				1	75	75	75	3		0.00	150.00	1	1	001
H1181	001	0		07	02	H1181_001_0	7																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1225	001	0	1	01	01	H1225_001_0	10																																																																																																																																		1	2		1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	See notes for details	2				1	100.00	100.00	100.00	1	2	3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	See notes for benefit details	2				3		50.00	100.00	1	2																															3	2	1	6	See notes for benefit details.	2				3		50.00	100.00	1	2	3	2	1	6	See notes for benefit details	2				3		50.00	100.00	1	2																3	2	1	6	 Anesthesia	2				1	50.00	50.00	50.00	1	2	001
H1230	001	0	1	01	01	H1230_001_0	10								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	003	0	1	01	01	H1230_003_0	10								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	013	0	1	01	01	H1230_013_0	10								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	014	0	1	01	01	H1230_014_0	10								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1278	003	0	1	04	01	H1278_003_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	004	0	1	04	01	H1278_004_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	005	0	1	04	01	H1278_005_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	007	0	1	04	01	H1278_007_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	009	0	1	04	01	H1278_009_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	010	0	1	04	01	H1278_010_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	013	0	1	04	01	H1278_013_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	014	0	1	04	01	H1278_014_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	015	0	1	04	01	H1278_015_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	016	0	1	04	01	H1278_016_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	020	0	1	04	01	H1278_020_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	021	0	1	04	01	H1278_021_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	022	0	1	04	01	H1278_022_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	024	0	1	04	01	H1278_024_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	028	0	1	04	01	H1278_028_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	029	0	1	04	01	H1278_029_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	030	0	1	04	01	H1278_030_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1278	032	0	1	04	01	H1278_032_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1350	026	0	1	01	01	H1350_026_0	5																																																																																																																																		1	2		1000.00	3		2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	028	0	1	01	01	H1350_028_0	5																			2					2				2					1	110110	20.00	20.00	20.00	2		3	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	3	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every five years	2								2	2																3	2	2	3		2								2	2	3	2	1	3		2								2	2																2						2					1	50.00	3	2	1	6	Same tooth surface restoration covered once in a two-year period.	1	20	20	20	2				1	2																																																																																											3	1				1	20	20	20	2				1	2																															001
H1350	029	0	1	01	01	H1350_029_0	5																			2					2				2					1	110110	20.00	20.00	20.00	2		3	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	3	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every five years.	2								2	2																3	2	2	3		2								2	2	3	2	1	3		2								2	2																2						2					1	50.00	3	2	1	6	Same tooth surface restoration covered once in a two-year period.	1	20	20	20	2				1	2																																																																																											3	1				1	20	20	20	2				1	2																															001
H1350	030	0	1	01	01	H1350_030_0	5																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1423	001	0	1	02	01	H1423_001_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	001	0	1	02	01	H1423_001_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	001	0	1	02	01	H1423_001_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	002	0	1	02	01	H1423_002_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	002	0	1	02	01	H1423_002_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	002	0	1	02	01	H1423_002_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	004	0	1	02	01	H1423_004_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	004	0	1	02	01	H1423_004_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	004	0	1	02	01	H1423_004_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	005	0	1	01	01	H1423_005_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	005	0	1	01	01	H1423_005_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	005	0	1	01	01	H1423_005_0	7																			2					1	500.00	3		2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	007	0	1	01	01	H1423_007_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	007	0	1	01	01	H1423_007_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	007	0	1	01	01	H1423_007_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	008	0	1	01	01	H1423_008_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	008	0	1	01	01	H1423_008_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	008	0	1	01	01	H1423_008_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	009	0	1	02	01	H1423_009_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	009	0	1	02	01	H1423_009_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	009	0	1	02	01	H1423_009_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1607	012	0	1	04	01	H1607_012_0	6	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1607	012	0	1	04	01	H1607_012_0	6	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1607	012	0	1	04	01	H1607_012_0	6	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1607	015	0	1	04	01	H1607_015_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1607	015	0	1	04	01	H1607_015_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1607	015	0	1	04	01	H1607_015_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1666	006	0	1	04	01	H1666_006_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H1666	012	0	1	04	01	H1666_012_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H1666	015	0	1	04	01	H1666_015_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H1666	019	0	1	04	01	H1666_019_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H1666	021	0	1	04	01	H1666_021_0	12																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1822	004	0	1	01	01	H1822_004_0	8	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H1846	005	0	1	04	01	H1846_005_0	6	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	005	0	1	04	01	H1846_005_0	6	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1846	006	0	1	04	01	H1846_006_0	6	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	006	0	1	04	01	H1846_006_0	6	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1846	007	0	1	04	01	H1846_007_0	7	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	007	0	1	04	01	H1846_007_0	7	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1889	013	0	1	04	01	H1889_013_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	015	0	1	04	01	H1889_015_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	016	0	1	04	01	H1889_016_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	017	0	1	04	01	H1889_017_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	020	0	1	04	01	H1889_020_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	022	0	1	04	01	H1889_022_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	023	0	1	04	01	H1889_023_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1889	025	0	1	04	01	H1889_025_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1894	008	0	1	02	01	H1894_008_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1894	008	0	1	02	01	H1894_008_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1894	008	0	1	02	01	H1894_008_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1961	020	0	1	02	01	H1961_020_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1961	023	0	1	02	01	H1961_023_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H1961	025	0	1	02	01	H1961_025_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	010	0	1	04	01	H2001_010_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	019	0	1	04	01	H2001_019_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	021	0	1	04	01	H2001_021_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	023	0	1	04	01	H2001_023_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	055	0	1	04	01	H2001_055_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	070	0	1	04	01	H2001_070_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	083	1	1	04	01	H2001_083_1	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	083	2	1	04	01	H2001_083_2	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	087	0	1	04	01	H2001_087_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	088	1	1	04	01	H2001_088_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	088	2	1	04	01	H2001_088_2	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	089	0	1	04	01	H2001_089_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	090	0	1	04	01	H2001_090_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	091	0	1	04	01	H2001_091_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	092	0	1	04	01	H2001_092_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	093	0	1	04	01	H2001_093_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	094	0	1	04	01	H2001_094_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	095	0	1	04	01	H2001_095_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	097	0	1	04	01	H2001_097_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	098	0	1	04	01	H2001_098_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	099	0	1	04	01	H2001_099_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	100	0	1	04	01	H2001_100_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	101	0	1	04	01	H2001_101_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	104	0	1	04	01	H2001_104_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	105	0	1	04	01	H2001_105_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	110	0	1	04	01	H2001_110_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	111	0	1	04	01	H2001_111_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	119	0	1	04	01	H2001_119_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	120	0	1	04	01	H2001_120_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	121	0	1	04	01	H2001_121_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	122	0	1	04	01	H2001_122_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	127	0	1	04	01	H2001_127_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	128	0	1	04	01	H2001_128_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	131	0	1	04	01	H2001_131_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	132	0	1	04	01	H2001_132_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	133	0	1	04	01	H2001_133_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	135	0	1	04	01	H2001_135_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2001	137	0	1	04	01	H2001_137_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2172	001	0	1	02	01	H2172_001_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	001	0	1	02	01	H2172_001_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	002	0	1	02	01	H2172_002_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	002	0	1	02	01	H2172_002_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	003	0	1	02	01	H2172_003_0	9								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	003	0	1	02	01	H2172_003_0	9								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	004	0	1	02	01	H2172_004_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	004	0	1	02	01	H2172_004_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	005	0	1	01	01	H2172_005_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	005	0	1	01	01	H2172_005_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs and relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	006	0	1	01	01	H2172_006_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	006	0	1	01	01	H2172_006_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	008	0	1	02	01	H2172_008_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	008	0	1	02	01	H2172_008_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	009	0	1	02	01	H2172_009_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	009	0	1	02	01	H2172_009_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	010	0	1	02	01	H2172_010_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	010	0	1	02	01	H2172_010_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	011	0	1	01	01	H2172_011_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	011	0	1	01	01	H2172_011_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	012	0	1	02	01	H2172_012_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	012	0	1	02	01	H2172_012_0	8								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	013	0	1	02	01	H2172_013_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	013	0	1	02	01	H2172_013_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	014	0	1	02	01	H2172_014_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	014	0	1	02	01	H2172_014_0	7								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2235	001	0	1	01	01	H2235_001_0	10	1	1	1		1	1		2	2	2	1	2				1																																																																																																																		1	2		4000.00	3		2					2		3	2	1	6	1 Filling per tooth every 24 months2 Crowns covered every calendar year	2				2				2	2	3	2	3	3		2				2				2	2																3	2	1	6	1 denture per arch every 5 calendar years1 partial denture per arch every 5 calendar years2 relines every calendar year	2				2				2	2																																																																																											001
H2235	002	0	1	01	01	H2235_002_0	9	1	1	1		1	1		2	2	2	1	2				1																																																																																																																		1	2		4000.00	3		2					2		3	2	1	6	1 filling per tooth every 24 months2 crowns covered every calendar year	2				2				2	2	3	2	3	3		2				2				2	2																3	2	1	6	1 denture per arch every 5 calendar years1 partial denture per arch every 5 calendar years2 relines every calendar year	2				2				2	2																																																																																											001
H2235	003	0	1	01	01	H2235_003_0	10	1	1	1		1	1		2	2	2	1	2				1																																																																																																																		1	2		4000.00	3		2					2		3	2	1	6	1 filling per tooth every 24 months2 crowns covered every calendar year	2				2				2	2	3	2	3	3		2				2				2	2																3	2	1	6	1 denture per arch every 5 calendar years1 partial denture per arch every 5 calendar years2 relines every calendar year	2				2				2	2																																																																																											001
H2256	001	1	1	01	01	H2256_001_1	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	001	2	1	01	01	H2256_001_2	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	001	6	1	01	01	H2256_001_6	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	1	1	01	01	H2256_015_1	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	2	1	01	01	H2256_015_2	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	6	1	01	01	H2256_015_6	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	016	1	1	01	01	H2256_016_1	3																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	016	2	1	01	01	H2256_016_2	3																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	1	1	01	01	H2256_018_1	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	7	1	01	01	H2256_018_7	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	8	1	01	01	H2256_018_8	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	019	1	1	01	01	H2256_019_1	3	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	019	7	1	01	01	H2256_019_7	3	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	1	1	01	01	H2256_026_1	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	2	1	01	01	H2256_026_2	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	3	1	01	01	H2256_026_3	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	028	0	1	01	01	H2256_028_0	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	033	0	1	01	01	H2256_033_0	5																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	034	0	1	01	01	H2256_034_0	5	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	036	0	1	01	01	H2256_036_0	4	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	039	0	1	01	01	H2256_039_0	3																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	040	0	1	01	01	H2256_040_0	3	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	041	0	1	01	01	H2256_041_0	3	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	042	0	1	01	01	H2256_042_0	3	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2320	022	1	1	02	01	H2320_022_1	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	2	1	02	01	H2320_022_2	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	3	1	02	01	H2320_022_3	5								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	4	1	02	01	H2320_022_4	5								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	5	1	02	01	H2320_022_5	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	1	1	02	01	H2320_028_1	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	2	1	02	01	H2320_028_2	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	3	1	02	01	H2320_028_3	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	4	1	02	01	H2320_028_4	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	5	1	02	01	H2320_028_5	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	1	1	02	01	H2320_029_1	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	2	1	02	01	H2320_029_2	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	3	1	02	01	H2320_029_3	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	4	1	02	01	H2320_029_4	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	5	1	02	01	H2320_029_5	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	031	0	1	02	01	H2320_031_0	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2322	008	0	1	04	01	H2322_008_0	8								2			2								1	2	2000.00	3		2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2322	011	0	1	04	01	H2322_011_0	7								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2322	016	0	1	04	01	H2322_016_0	8								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	015	0	1	01	01	H2354_015_0	8								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	018	0	1	01	01	H2354_018_0	7								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	021	0	1	02	01	H2354_021_0	8								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	028	0	1	01	01	H2354_028_0	9								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2406	039	0	1	04	01	H2406_039_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	040	0	1	04	01	H2406_040_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	041	0	1	04	01	H2406_041_0	4	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	060	0	1	04	01	H2406_060_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	061	0	1	04	01	H2406_061_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	064	0	1	04	01	H2406_064_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	066	0	1	04	01	H2406_066_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	067	0	1	04	01	H2406_067_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	069	0	1	04	01	H2406_069_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	070	0	1	04	01	H2406_070_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	071	0	1	04	01	H2406_071_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	072	0	1	04	01	H2406_072_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	075	0	1	04	01	H2406_075_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	076	0	1	04	01	H2406_076_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	081	0	1	04	01	H2406_081_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	083	0	1	04	01	H2406_083_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	084	0	1	04	01	H2406_084_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	085	0	1	04	01	H2406_085_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	086	0	1	04	01	H2406_086_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	087	0	1	04	01	H2406_087_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	090	0	1	04	01	H2406_090_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	091	0	1	04	01	H2406_091_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	095	0	1	04	01	H2406_095_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	096	0	1	04	01	H2406_096_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	097	0	1	04	01	H2406_097_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	101	0	1	04	01	H2406_101_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	102	0	1	04	01	H2406_102_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	103	0	1	04	01	H2406_103_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	104	0	1	04	01	H2406_104_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	105	0	1	04	01	H2406_105_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	106	0	1	04	01	H2406_106_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	111	0	1	04	01	H2406_111_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	112	0	1	04	01	H2406_112_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	113	0	1	04	01	H2406_113_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	119	0	1	04	01	H2406_119_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	122	0	1	04	01	H2406_122_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	125	0	1	04	01	H2406_125_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2406	134	0	1	04	01	H2406_134_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2459	021	1	1	02	01	H2459_021_1	12								2			2																																																																																																																							2						2					1	50.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H2459	021	2	1	02	01	H2459_021_2	12								2			2																																																																																																																							2						2					1	50.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H2459	021	3	1	02	01	H2459_021_3	13								2			2																																																																																																																							2						2					1	50.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H2459	023	1	1	02	01	H2459_023_1	10	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					1	75.00	3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H2459	023	2	1	02	01	H2459_023_2	10	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					1	75.00	3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H2459	024	0	1	02	01	H2459_024_0	10	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					1	75.00	3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H2459	030	0	1	02	01	H2459_030_0	10	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	X-rays: Four periapical (Pas) once per calendar year. Full mouth x-rays every five years.	2				2				2	2																3	2	1	3		2				2				2	2																															2						2					1	75.00	3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H2462	027	0	1	18	06	H2462_027_0	4																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to once per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2		500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2462	028	0	1	18	06	H2462_028_0	4																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to once per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2		500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2582	004	0	1	02	01	H2582_004_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2582	005	0	1	02	01	H2582_005_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2593	001	0	1	02	01	H2593_001_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	001	0	1	02	01	H2593_001_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	001	0	1	02	01	H2593_001_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	003	0	1	01	01	H2593_003_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	003	0	1	01	01	H2593_003_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	003	0	1	01	01	H2593_003_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	005	0	1	02	01	H2593_005_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	005	0	1	02	01	H2593_005_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	005	0	1	02	01	H2593_005_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	006	0	1	02	01	H2593_006_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	006	0	1	02	01	H2593_006_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	006	0	1	02	01	H2593_006_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	029	0	1	02	01	H2593_029_0	8	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	029	0	1	02	01	H2593_029_0	8	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	029	0	1	02	01	H2593_029_0	8	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	040	0	1	02	01	H2593_040_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	040	0	1	02	01	H2593_040_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	040	0	1	02	01	H2593_040_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	043	0	1	02	01	H2593_043_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	043	0	1	02	01	H2593_043_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	043	0	1	02	01	H2593_043_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2802	001	0	1	02	01	H2802_001_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	008	0	1	02	01	H2802_008_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	010	0	1	02	01	H2802_010_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	012	0	1	02	01	H2802_012_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	018	0	1	02	01	H2802_018_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	030	0	1	02	01	H2802_030_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	048	0	1	02	01	H2802_048_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	054	0	1	02	01	H2802_054_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	059	0	1	02	01	H2802_059_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	063	0	1	02	01	H2802_063_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	068	0	1	02	01	H2802_068_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	070	0	1	02	01	H2802_070_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2802	071	0	1	02	01	H2802_071_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H2836	005	0	1	04	01	H2836_005_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2836	005	0	1	04	01	H2836_005_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2836	005	0	1	04	01	H2836_005_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3138	001	0	1	04	01	H3138_001_0	10								2	2	2	2			2																																																																																																																				1	2	2	1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3138	002	0	1	04	01	H3138_002_0	10								2	2	2	2			2																																																																																																																				1	2	2	1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3138	003	0	1	04	01	H3138_003_0	9								2	2	2	2			2																																																																																																																				1	2	2	1000.00	3		2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3152	082	0	1	01	01	H3152_082_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3152	098	0	1	01	01	H3152_098_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3204	001	0	1	01	01	H3204_001_0	4																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	007	0	1	01	01	H3204_007_0	4																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	008	0	1	01	01	H3204_008_0	3																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	015	0	1	02	01	H3204_015_0	4																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	016	0	1	01	01	H3204_016_0	4																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3312	002	0	1	01	01	H3312_002_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	064	0	1	01	01	H3312_064_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	079	0	1	01	01	H3312_079_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	081	0	1	01	01	H3312_081_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	082	0	1	01	01	H3312_082_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3342	023	1	1	04	01	H3342_023_1	7																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3342	023	1	1	04	01	H3342_023_1	7																			1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3342	023	1	1	04	01	H3342_023_1	7																			1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3342	023	2	1	04	01	H3342_023_2	7																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3342	023	2	1	04	01	H3342_023_2	7																			1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3342	023	2	1	04	01	H3342_023_2	7																			1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3379	001	0	1	02	01	H3379_001_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	041	0	1	02	01	H3379_041_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	043	0	1	02	01	H3379_043_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	045	0	1	02	01	H3379_045_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	050	0	1	02	01	H3379_050_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	051	0	1	02	01	H3379_051_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	053	0	1	02	01	H3379_053_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	054	0	1	02	01	H3379_054_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3379	056	0	1	02	01	H3379_056_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	001	0	1	04	01	H3418_001_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	002	0	1	04	01	H3418_002_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	004	0	1	04	01	H3418_004_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	007	0	1	04	01	H3418_007_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	008	0	1	04	01	H3418_008_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	009	0	1	04	01	H3418_009_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3418	010	0	1	04	01	H3418_010_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3443	005	0	1	01	01	H3443_005_0	8	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3447	013	0	1	02	01	H3447_013_0	9	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	013	0	1	02	01	H3447_013_0	9	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	013	0	1	02	01	H3447_013_0	9	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	024	0	1	02	01	H3447_024_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	024	0	1	02	01	H3447_024_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	024	0	1	02	01	H3447_024_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	025	0	1	02	01	H3447_025_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	025	0	1	02	01	H3447_025_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	025	0	1	02	01	H3447_025_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	033	0	1	02	01	H3447_033_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	033	0	1	02	01	H3447_033_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	033	0	1	02	01	H3447_033_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	037	0	1	02	01	H3447_037_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	037	0	1	02	01	H3447_037_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	037	0	1	02	01	H3447_037_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	038	1	1	02	01	H3447_038_1	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	038	1	1	02	01	H3447_038_1	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	038	1	1	02	01	H3447_038_1	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	038	2	1	02	01	H3447_038_2	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	038	2	1	02	01	H3447_038_2	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	038	2	1	02	01	H3447_038_2	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	039	0	1	02	01	H3447_039_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	039	0	1	02	01	H3447_039_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	039	0	1	02	01	H3447_039_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	1	1	02	01	H3447_042_1	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	1	1	02	01	H3447_042_1	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	1	1	02	01	H3447_042_1	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	2	1	02	01	H3447_042_2	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	2	1	02	01	H3447_042_2	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	2	1	02	01	H3447_042_2	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	3	1	02	01	H3447_042_3	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	3	1	02	01	H3447_042_3	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	3	1	02	01	H3447_042_3	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	4	1	02	01	H3447_042_4	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	4	1	02	01	H3447_042_4	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	4	1	02	01	H3447_042_4	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	043	0	1	02	01	H3447_043_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	043	0	1	02	01	H3447_043_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	043	0	1	02	01	H3447_043_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	049	0	1	02	01	H3447_049_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	049	0	1	02	01	H3447_049_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	049	0	1	02	01	H3447_049_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	050	0	1	02	01	H3447_050_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	050	0	1	02	01	H3447_050_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	050	0	1	02	01	H3447_050_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	051	0	1	02	01	H3447_051_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	051	0	1	02	01	H3447_051_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	051	0	1	02	01	H3447_051_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	052	0	1	02	01	H3447_052_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	052	0	1	02	01	H3447_052_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	052	0	1	02	01	H3447_052_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	054	0	1	02	01	H3447_054_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	054	0	1	02	01	H3447_054_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	054	0	1	02	01	H3447_054_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3528	011	1	1	02	01	H3528_011_1	12																																																																																																																																		1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	011	1	1	02	01	H3528_011_1	12																																																																																																																																		1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	011	1	1	02	01	H3528_011_1	12	2	2	2	2	2	2	2												1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3528	011	2	1	02	01	H3528_011_2	12																																																																																																																																		1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	011	2	1	02	01	H3528_011_2	12																																																																																																																																		1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	011	2	1	02	01	H3528_011_2	12	2	2	2	2	2	2	2												1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3528	015	0	1	02	01	H3528_015_0	12																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	015	0	1	02	01	H3528_015_0	12																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	015	0	1	02	01	H3528_015_0	12																			1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3528	016	0	1	02	01	H3528_016_0	12																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	016	0	1	02	01	H3528_016_0	12																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	016	0	1	02	01	H3528_016_0	12																			1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3536	002	0	1	02	01	H3536_002_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3536	002	0	1	02	01	H3536_002_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3536	002	0	1	02	01	H3536_002_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	034	0	1	02	01	H3655_034_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	034	0	1	02	01	H3655_034_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	034	0	1	02	01	H3655_034_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	041	0	1	02	01	H3655_041_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	041	0	1	02	01	H3655_041_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	041	0	1	02	01	H3655_041_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	1	1	02	01	H3655_045_1	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	1	1	02	01	H3655_045_1	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	1	1	02	01	H3655_045_1	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	2	1	02	01	H3655_045_2	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	2	1	02	01	H3655_045_2	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	2	1	02	01	H3655_045_2	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	3	1	02	01	H3655_045_3	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	3	1	02	01	H3655_045_3	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	3	1	02	01	H3655_045_3	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	4	1	02	01	H3655_045_4	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	4	1	02	01	H3655_045_4	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	4	1	02	01	H3655_045_4	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	047	0	1	02	01	H3655_047_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	047	0	1	02	01	H3655_047_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	047	0	1	02	01	H3655_047_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3660	028	0	1	02	01	H3660_028_0	9								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	029	0	1	02	01	H3660_029_0	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	044	0	1	01	01	H3660_044_0	9								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	050	0	1	01	01	H3660_050_0	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	052	1	1	01	01	H3660_052_1	7								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period, once per 5-year period or once per lifetime.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	052	2	1	01	01	H3660_052_2	7								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	053	1	1	01	01	H3660_053_1	10								2	2		2					2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Periodontal surgical procedures are payable once per 36-month period.	1	50	50	50	2				2	2																																																													3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	053	2	1	01	01	H3660_053_2	10								2	2		2					2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Periodontal surgical procedures are payable once per 36-month period.	1	50	50	50	2				2	2																																																													3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	056	1	1	01	01	H3660_056_1	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	056	2	1	01	01	H3660_056_2	10								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3668	013	0	1	01	01	H3668_013_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	013	0	1	01	01	H3668_013_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	018	1	1	01	01	H3668_018_1	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	018	1	1	01	01	H3668_018_1	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	018	2	1	01	01	H3668_018_2	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	018	2	1	01	01	H3668_018_2	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	019	1	1	01	01	H3668_019_1	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	019	1	1	01	01	H3668_019_1	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	019	2	1	01	01	H3668_019_2	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	019	2	1	01	01	H3668_019_2	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	020	0	1	01	01	H3668_020_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	020	0	1	01	01	H3668_020_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	022	0	1	01	01	H3668_022_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	022	0	1	01	01	H3668_022_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	023	0	1	01	01	H3668_023_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	023	0	1	01	01	H3668_023_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	025	0	1	01	01	H3668_025_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	025	0	1	01	01	H3668_025_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	026	0	1	01	01	H3668_026_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	026	0	1	01	01	H3668_026_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	029	0	1	01	01	H3668_029_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	029	0	1	01	01	H3668_029_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3672	013	0	1	01	01	H3672_013_0	10								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	014	0	1	01	01	H3672_014_0	7								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	020	0	1	01	01	H3672_020_0	7								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	021	0	1	01	01	H3672_021_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	023	0	1	01	01	H3672_023_0	7								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years.	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	024	0	1	01	01	H3672_024_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3805	015	0	1	02	01	H3805_015_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	017	0	1	02	01	H3805_017_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	032	0	1	02	01	H3805_032_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	033	0	1	02	01	H3805_033_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	037	0	1	02	01	H3805_037_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	039	1	1	02	01	H3805_039_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	039	2	1	02	01	H3805_039_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	040	0	1	02	01	H3805_040_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3805	043	0	1	02	01	H3805_043_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H3815	007	0	1	01	01	H3815_007_0	16	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	008	0	1	01	01	H3815_008_0	12	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	010	0	1	01	01	H3815_010_0	12	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	011	0	1	01	01	H3815_011_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	013	0	1	01	01	H3815_013_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	019	0	1	01	01	H3815_019_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	020	0	1	01	01	H3815_020_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	021	0	1	01	01	H3815_021_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	023	0	1	01	01	H3815_023_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	028	0	1	01	01	H3815_028_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	031	0	1	01	01	H3815_031_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	033	0	1	01	01	H3815_033_0	9	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	034	0	1	01	01	H3815_034_0	11																			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	035	0	1	01	01	H3815_035_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	037	0	1	01	01	H3815_037_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	038	0	1	01	01	H3815_038_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	040	0	1	01	01	H3815_040_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	043	0	1	01	01	H3815_043_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	046	0	1	01	01	H3815_046_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	047	0	1	01	01	H3815_047_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				2				3		20.00	425.00	2	2																															3	1				2				3		40.00	425.00	2	2	3	1				1	50	50	50	2				2	2																															001
H3815	048	0	1	01	01	H3815_048_0	10	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3822	001	0	1	01	01	H3822_001_0	10								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H3822	007	0	1	02	01	H3822_007_0	9								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H3828	001	0	1	04	01	H3828_001_0	7	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3828	001	0	1	04	01	H3828_001_0	7	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3890	002	0	1	04	01	H3890_002_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	See notes for benefit details	2				1	100.00	100.00	100.00	1	2	3	2	1	6	See notes for benefit details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	See notes for benefit details.	2				3		50.00	100.00	1	2																															3	2	1	6	See notes for benefit details.	2				3		50.00	100.00	1	2	3	2	1	6	See notes for benefit details	2				3		50.00	100.00	1	2																3	2	1	6	 Anesthesia	2				1	50.00	50.00	50.00	1	2	001
H3924	059	21	1	04	01	H3924_059_21	3																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3924	059	22	1	04	01	H3924_059_22	3																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3924	065	0	1	04	01	H3924_065_0	3																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	7	2	2	2		2	2													1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	7	2	2	2		2	2													1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	008	0	1	04	01	H4036_008_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	017	0	1	04	01	H4036_017_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	017	0	1	04	01	H4036_017_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	017	0	1	04	01	H4036_017_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	020	0	1	04	01	H4036_020_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	020	0	1	04	01	H4036_020_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	020	0	1	04	01	H4036_020_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	022	0	1	04	01	H4036_022_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	022	0	1	04	01	H4036_022_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	022	0	1	04	01	H4036_022_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	024	0	1	04	01	H4036_024_0	6	2	2	2		2	2		2	2	2	2					2		2	1	1	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	024	0	1	04	01	H4036_024_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	024	0	1	04	01	H4036_024_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	025	0	1	04	01	H4036_025_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	025	0	1	04	01	H4036_025_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	025	0	1	04	01	H4036_025_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	026	0	1	04	01	H4036_026_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	026	0	1	04	01	H4036_026_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	026	0	1	04	01	H4036_026_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	028	0	1	04	01	H4036_028_0	9	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	028	0	1	04	01	H4036_028_0	9	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	028	0	1	04	01	H4036_028_0	9	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	029	0	1	04	01	H4036_029_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	029	0	1	04	01	H4036_029_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	029	0	1	04	01	H4036_029_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	030	0	1	04	01	H4036_030_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	030	0	1	04	01	H4036_030_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	030	0	1	04	01	H4036_030_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	033	0	1	04	01	H4036_033_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	033	0	1	04	01	H4036_033_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	033	0	1	04	01	H4036_033_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	034	0	1	04	01	H4036_034_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	034	0	1	04	01	H4036_034_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	034	0	1	04	01	H4036_034_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	035	0	1	04	01	H4036_035_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	035	0	1	04	01	H4036_035_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	035	0	1	04	01	H4036_035_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	036	0	1	04	01	H4036_036_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	036	0	1	04	01	H4036_036_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	036	0	1	04	01	H4036_036_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	037	0	1	04	01	H4036_037_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	037	0	1	04	01	H4036_037_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	037	0	1	04	01	H4036_037_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	038	0	1	04	01	H4036_038_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	038	0	1	04	01	H4036_038_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	038	0	1	04	01	H4036_038_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	040	0	1	04	01	H4036_040_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	040	0	1	04	01	H4036_040_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	040	0	1	04	01	H4036_040_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	041	0	1	04	01	H4036_041_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	041	0	1	04	01	H4036_041_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	041	0	1	04	01	H4036_041_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	042	0	1	04	01	H4036_042_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	042	0	1	04	01	H4036_042_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	042	0	1	04	01	H4036_042_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	002	0	1	02	01	H4161_002_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	002	0	1	02	01	H4161_002_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	002	0	1	02	01	H4161_002_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	004	0	1	02	01	H4161_004_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	004	0	1	02	01	H4161_004_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	004	0	1	02	01	H4161_004_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	005	0	1	02	01	H4161_005_0	7	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	005	0	1	02	01	H4161_005_0	7	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	005	0	1	02	01	H4161_005_0	7	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	006	0	1	02	01	H4161_006_0	7	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	006	0	1	02	01	H4161_006_0	7	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	006	0	1	02	01	H4161_006_0	7	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	007	0	1	02	01	H4161_007_0	7	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	007	0	1	02	01	H4161_007_0	7	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	007	0	1	02	01	H4161_007_0	7	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	009	0	1	02	01	H4161_009_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	009	0	1	02	01	H4161_009_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	009	0	1	02	01	H4161_009_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	010	0	1	02	01	H4161_010_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	010	0	1	02	01	H4161_010_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	010	0	1	02	01	H4161_010_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	011	0	1	02	01	H4161_011_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	011	0	1	02	01	H4161_011_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	011	0	1	02	01	H4161_011_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	012	0	1	02	01	H4161_012_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	012	0	1	02	01	H4161_012_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	012	0	1	02	01	H4161_012_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	013	0	1	02	01	H4161_013_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	013	0	1	02	01	H4161_013_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	013	0	1	02	01	H4161_013_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	014	0	1	02	01	H4161_014_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	014	0	1	02	01	H4161_014_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	014	0	1	02	01	H4161_014_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	015	0	1	02	01	H4161_015_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	015	0	1	02	01	H4161_015_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	015	0	1	02	01	H4161_015_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	016	0	1	02	01	H4161_016_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	016	0	1	02	01	H4161_016_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	016	0	1	02	01	H4161_016_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	017	0	1	02	01	H4161_017_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	017	0	1	02	01	H4161_017_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	017	0	1	02	01	H4161_017_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	001	0	1	02	01	H4346_001_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	001	0	1	02	01	H4346_001_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	001	0	1	02	01	H4346_001_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	005	0	1	02	01	H4346_005_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	005	0	1	02	01	H4346_005_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	005	0	1	02	01	H4346_005_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	006	0	1	02	01	H4346_006_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	006	0	1	02	01	H4346_006_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	006	0	1	02	01	H4346_006_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	010	0	1	01	01	H4346_010_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	010	0	1	01	01	H4346_010_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	010	0	1	01	01	H4346_010_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	012	0	1	01	01	H4346_012_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	012	0	1	01	01	H4346_012_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	012	0	1	01	01	H4346_012_0	7																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	017	0	1	02	01	H4346_017_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	017	0	1	02	01	H4346_017_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	017	0	1	02	01	H4346_017_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	019	0	1	02	01	H4346_019_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	019	0	1	02	01	H4346_019_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	019	0	1	02	01	H4346_019_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	029	0	1	02	01	H4346_029_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	029	0	1	02	01	H4346_029_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	029	0	1	02	01	H4346_029_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4497	001	1	1	04	01	H4497_001_1	5																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	001	2	1	04	01	H4497_001_2	5																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	001	3	1	04	01	H4497_001_3	5																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	1	1	04	01	H4497_002_1	5																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	2	1	04	01	H4497_002_2	5																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	3	1	04	01	H4497_002_3	5																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	005	3	1	04	01	H4497_005_3	5	2			2				2	1	1	1	1		1	1	2		1	1	2	1000.00	3		2														2																																3	1				2				2				2	2																																														1	1					2					2																																																																																																											3	1				2				2				2	2																															001
H4497	005	4	1	04	01	H4497_005_4	5	2			2				2	1	1	1					2		1	1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H4514	007	0	1	02	01	H4514_007_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4527	024	0	1	02	01	H4527_024_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4527	037	0	1	02	01	H4527_037_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4527	048	0	1	02	01	H4527_048_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4527	051	0	1	02	01	H4527_051_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4527	053	0	1	02	01	H4527_053_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4544	001	0	1	04	01	H4544_001_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4604	011	0	1	02	01	H4604_011_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4604	020	0	1	02	01	H4604_020_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4604	022	0	1	02	01	H4604_022_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4604	024	0	1	02	01	H4604_024_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4604	025	0	1	02	01	H4604_025_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H4801	002	0	1	04	01	H4801_002_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H4801	007	0	1	04	01	H4801_007_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H4801	015	0	1	04	01	H4801_015_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H4801	019	0	1	04	01	H4801_019_0	5								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H4801	020	0	1	04	01	H4801_020_0	5								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H4801	023	0	1	04	01	H4801_023_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H4875	016	1	1	04	01	H4875_016_1	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	2	1	04	01	H4875_016_2	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	3	1	04	01	H4875_016_3	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	4	1	04	01	H4875_016_4	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	5	1	04	01	H4875_016_5	5								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	1	1	04	01	H4875_018_1	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	2	1	04	01	H4875_018_2	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	3	1	04	01	H4875_018_3	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	4	1	04	01	H4875_018_4	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	5	1	04	01	H4875_018_5	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	020	1	1	04	01	H4875_020_1	6								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	020	2	1	04	01	H4875_020_2	6								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	020	3	1	04	01	H4875_020_3	6								2								2			2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	022	1	1	04	01	H4875_022_1	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	022	2	1	04	01	H4875_022_2	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	022	5	1	04	01	H4875_022_5	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	024	1	1	04	01	H4875_024_1	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	024	2	1	04	01	H4875_024_2	6								2	2							2		2	2					2														2																																																														3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4882	003	0	1	04	01	H4882_003_0	8	2	2	2	2	2	2	2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	009	1	1	04	01	H4882_009_1	7	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	009	2	1	04	01	H4882_009_2	9	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	010	1	1	04	01	H4882_010_1	9	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	010	2	1	04	01	H4882_010_2	10	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	011	1	1	04	01	H4882_011_1	7	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	011	2	1	04	01	H4882_011_2	8	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	013	0	1	04	01	H4882_013_0	8	2	2	2	2	2	2	2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	014	0	1	04	01	H4909_014_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	014	0	1	04	01	H4909_014_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	014	0	1	04	01	H4909_014_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	020	0	1	04	01	H4909_020_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	020	0	1	04	01	H4909_020_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	020	0	1	04	01	H4909_020_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	021	0	1	04	01	H4909_021_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	021	0	1	04	01	H4909_021_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	021	0	1	04	01	H4909_021_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	023	0	1	04	01	H4909_023_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	023	0	1	04	01	H4909_023_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	023	0	1	04	01	H4909_023_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	026	0	1	04	01	H4909_026_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	026	0	1	04	01	H4909_026_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	026	0	1	04	01	H4909_026_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4937	001	0	1	04	01	H4937_001_0	6	2	2	2	2	1	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2																3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, crown  resin with high noble metal covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Adjust complete denture - maxillary covered once every 6 months from last date of service, complete denture  maxillary covered once every 60 months from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	20	20	20	2				2	2	001
H4937	002	0	1	04	01	H4937_002_0	7	2	2	2	2	1	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	20	2				2	2																3	2	1	3		2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	2				2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, crown  resin with high noble metal covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Adjust complete denture - maxillary covered once every 6 months from last date of service, complete denture  maxillary covered once every 60 months from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by covered benefit. See Notes for more details.	1	20	20	20	2				2	2	001
H4961	001	0	1	04	01	H4961_001_0	12																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H4961	003	0	1	04	01	H4961_003_0	8																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H4961	006	0	1	04	01	H4961_006_0	12																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H5050	001	0	1	01	01	H5050_001_0	3																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	004	0	1	01	01	H5050_004_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	009	0	1	01	01	H5050_009_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	013	0	1	01	01	H5050_013_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	017	0	1	01	01	H5050_017_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	019	0	1	01	01	H5050_019_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	021	0	1	01	01	H5050_021_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	022	0	1	01	01	H5050_022_0	5																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	023	0	1	01	01	H5050_023_0	4																																																																																																																																		2						2					1	100.00	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5163	001	0	1	01	01	H5163_001_0	7	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	2		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	2	2	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	6	Per Tooth per 5 calendar years	1	50	50	50	2				2	2	3	2	3	3		1	50	50	50	2				2	2																3	2	2	3		1	50	50	50	2				2	2	001
H5163	002	0	1	01	01	H5163_002_0	7	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	2		2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	2	2	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	6	Per Tooth per 5 calendar years	1	50	50	50	2				2	2	3	2	3	3		1	50	50	50	2				2	2																3	2	2	3		1	50	50	50	2				2	2	001
H5211	001	0	1	02	01	H5211_001_0	9	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray. Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	002	0	1	02	01	H5211_002_0	6	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	003	0	1	02	01	H5211_003_0	5	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	004	0	1	02	01	H5211_004_0	6	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	010	0	1	01	01	H5211_010_0	5	2	2	2		2														2					2				2					2					2		3	2	1	3		3		0	20	2				2	2	3	2	0	3		3		0	20	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	3		3		20	50	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		0	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	012	0	1	02	01	H5211_012_0	11	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5215	002	0	1	04	01	H5215_002_0	23	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5215	005	0	1	04	01	H5215_005_0	9	2	2			2														2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5215	008	0	1	04	01	H5215_008_0	8	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5215	009	0	1	04	01	H5215_009_0	10	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5215	012	0	1	04	01	H5215_012_0	9	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5244	001	0	1	01	01	H5244_001_0	9	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5253	034	0	1	02	01	H5253_034_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	040	0	1	02	01	H5253_040_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	051	0	1	02	01	H5253_051_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	062	0	1	02	01	H5253_062_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	072	0	1	02	01	H5253_072_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	079	0	1	02	01	H5253_079_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	097	0	1	02	01	H5253_097_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	105	0	1	02	01	H5253_105_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	107	3	1	02	01	H5253_107_3	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	108	4	1	02	01	H5253_108_4	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	110	0	1	02	01	H5253_110_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	119	0	1	02	01	H5253_119_0	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	120	0	1	02	01	H5253_120_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	121	0	1	02	01	H5253_121_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	125	1	1	02	01	H5253_125_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	127	0	1	02	01	H5253_127_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	135	0	1	02	01	H5253_135_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	144	1	1	02	01	H5253_144_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	144	2	1	02	01	H5253_144_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	154	0	1	02	01	H5253_154_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	155	0	1	02	01	H5253_155_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	157	2	1	02	01	H5253_157_2	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	159	0	1	02	01	H5253_159_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	161	0	1	02	01	H5253_161_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	162	2	1	02	01	H5253_162_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	164	1	1	02	01	H5253_164_1	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	164	2	1	02	01	H5253_164_2	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	165	1	1	02	01	H5253_165_1	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	165	2	1	02	01	H5253_165_2	5	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	169	0	1	02	01	H5253_169_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	175	0	1	02	01	H5253_175_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	176	0	1	02	01	H5253_176_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	179	0	1	02	01	H5253_179_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	180	0	1	02	01	H5253_180_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	182	0	1	02	01	H5253_182_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	183	0	1	02	01	H5253_183_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	186	0	1	02	01	H5253_186_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	188	0	1	02	01	H5253_188_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	189	0	1	02	01	H5253_189_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	192	0	1	02	01	H5253_192_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	195	0	1	02	01	H5253_195_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	196	0	1	02	01	H5253_196_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	197	0	1	02	01	H5253_197_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5253	198	0	1	02	01	H5253_198_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5262	001	0	1	01	01	H5262_001_0	7	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	003	0	1	01	01	H5262_003_0	7	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	004	0	1	01	01	H5262_004_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	005	0	1	01	01	H5262_005_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	007	0	1	01	01	H5262_007_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	008	0	1	01	01	H5262_008_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	009	0	1	01	01	H5262_009_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	010	0	1	01	01	H5262_010_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	011	0	1	01	01	H5262_011_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	012	0	1	01	01	H5262_012_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	013	0	1	01	01	H5262_013_0	5	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	018	0	1	01	01	H5262_018_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	019	0	1	01	01	H5262_019_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	020	0	1	01	01	H5262_020_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	021	0	1	01	01	H5262_021_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	023	0	1	01	01	H5262_023_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	024	0	1	01	01	H5262_024_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	025	0	1	01	01	H5262_025_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	026	0	1	01	01	H5262_026_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	027	0	1	01	01	H5262_027_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5296	006	0	1	01	01	H5296_006_0	8	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5296	008	0	1	01	01	H5296_008_0	9	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5322	040	0	1	02	01	H5322_040_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5322	041	0	1	02	01	H5322_041_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5322	043	0	1	02	01	H5322_043_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5386	003	0	1	01	01	H5386_003_0	10																			2					2				2					2					2		3	1				2				3		0.00	5.00	1	1	3	2	1	4		2				2				1	1	3	1				2				3		0.00	5.00	1	1	3	2	1	4		2				1	15.00	15.00	15.00	1	1																3	1				2				3		0.00	150.00	1	1	2						2					2		3	1				2				3		20.00	425.00	1	1	3	1				2				3		0.00	475.00	1	1	3	1				2				3		0.00	450.00	1	1	3	1				2				3		20.00	495.00	1	1																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	1	1																3	1				2				3		0.00	50.00	1	1	001
H5386	003	0	1	01	01	H5386_003_0	10																			2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	002
H5386	004	0	1	01	01	H5386_004_0	10	2	2	2	2	2		2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	001
H5386	005	0	1	01	01	H5386_005_0	10	2	2	2	2	2		2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	001
H5422	011	0	1	02	01	H5422_011_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	011	0	1	02	01	H5422_011_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	011	0	1	02	01	H5422_011_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5422	014	0	1	02	01	H5422_014_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	014	0	1	02	01	H5422_014_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	014	0	1	02	01	H5422_014_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5422	015	0	1	02	01	H5422_015_0	9	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	015	0	1	02	01	H5422_015_0	9	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	015	0	1	02	01	H5422_015_0	9	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5425	001	0	1	01	01	H5425_001_0	10	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	005	0	1	01	01	H5425_005_0	9																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				3		0.00	180.00	2	2	3	2	2	3		2				2				2	2																3	1				2				3		0.00	267.00	2	2	2						2					2		3	1				2				3		34.00	595.00	2	2	3	1				2				3		35.00	615.00	2	2	3	1				2				3		0.00	648.00	2	2	3	1				2				3		29.00	803.00	2	2																															3	1				2				3		77.00	595.00	2	2	3	1				2				3		0.00	362.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	005	0	1	01	01	H5425_005_0	9																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	2	3		2				2				2	2																3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	002
H5425	006	0	1	01	01	H5425_006_0	13	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	007	0	1	01	01	H5425_007_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	008	0	1	01	01	H5425_008_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	009	0	1	01	01	H5425_009_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	019	0	1	01	01	H5425_019_0	9	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	034	0	1	01	01	H5425_034_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	065	0	1	01	01	H5425_065_0	10	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	069	0	1	01	01	H5425_069_0	10	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	075	0	1	01	01	H5425_075_0	10	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	082	0	1	01	01	H5425_082_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	086	0	1	01	01	H5425_086_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	087	0	1	01	01	H5425_087_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	091	0	1	02	01	H5425_091_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	092	0	1	01	01	H5425_092_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	096	0	1	01	01	H5425_096_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	100	0	1	01	01	H5425_100_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	101	0	1	01	01	H5425_101_0	9	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	104	0	1	01	01	H5425_104_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	105	0	1	01	01	H5425_105_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	107	0	1	01	01	H5425_107_0	8	2	1	1	2	1			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	5.00	2	2																															3	1				2				3		0.00	80.00	2	2	2						2					2		3	1				2				3		8.00	390.00	2	2	3	1				2				3		5.00	395.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		13.00	440.00	2	2																															3	1				2				3		25.00	395.00	2	2	3	1				2				3		0.00	140.00	2	2																3	1				2				3		0.00	125.00	2	2	001
H5425	108	0	1	01	01	H5425_108_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	109	0	1	01	01	H5425_109_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	121	0	1	01	01	H5425_121_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5472	003	0	1	02	01	H5472_003_0	8	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5521	040	0	1	04	01	H5521_040_0	2																																																																																																																																		1	2	2	2000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	120	0	1	04	01	H5521_120_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	121	0	1	04	01	H5521_121_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	123	0	1	04	01	H5521_123_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	124	0	1	04	01	H5521_124_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	277	0	1	04	01	H5521_277_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	511	0	1	04	01	H5521_511_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	512	0	1	04	01	H5521_512_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	514	0	1	04	01	H5521_514_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	515	0	1	04	01	H5521_515_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	520	0	1	04	01	H5521_520_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	521	0	1	04	01	H5521_521_0	2																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	536	0	1	04	01	H5521_536_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	537	0	1	04	01	H5521_537_0	2																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5649	001	0	1	01	01	H5649_001_0	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	006	0	1	01	01	H5649_006_0	7	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	008	0	1	01	01	H5649_008_0	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	018	0	1	01	01	H5649_018_0	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	019	0	1	01	01	H5649_019_0	9	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	022	0	1	01	01	H5649_022_0	7	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	023	0	1	01	01	H5649_023_0	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	025	1	1	01	01	H5649_025_1	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	025	2	1	01	01	H5649_025_2	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	027	0	1	01	01	H5649_027_0	7	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	028	0	1	01	01	H5649_028_0	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	029	0	1	01	01	H5649_029_0	8	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5649	030	0	1	01	01	H5649_030_0	10	2	2	2	2	2	2	2	2	2	2	2	2		2	2	2		2	2					2				2					2					2		3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	3	1				1	10	10	10	2				1	2	2						2					2		3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2	3	1				1	70	70	70	2				1	2																3	1				1	70	70	70	2				1	2	001
H5652	001	0	1	02	01	H5652_001_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5652	002	0	1	02	01	H5652_002_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5652	004	0	1	02	01	H5652_004_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5652	006	0	1	02	01	H5652_006_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5652	008	0	1	02	01	H5652_008_0	6	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H5828	008	0	1	02	01	H5828_008_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	008	0	1	02	01	H5828_008_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	008	0	1	02	01	H5828_008_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	013	0	1	02	01	H5828_013_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	013	0	1	02	01	H5828_013_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	013	0	1	02	01	H5828_013_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	014	0	1	02	01	H5828_014_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	014	0	1	02	01	H5828_014_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	014	0	1	02	01	H5828_014_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	015	0	1	02	01	H5828_015_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	015	0	1	02	01	H5828_015_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	015	0	1	02	01	H5828_015_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	016	0	1	02	01	H5828_016_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	016	0	1	02	01	H5828_016_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	016	0	1	02	01	H5828_016_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	017	0	1	02	01	H5828_017_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	017	0	1	02	01	H5828_017_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	017	0	1	02	01	H5828_017_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5843	002	0	1	01	01	H5843_002_0	6																																																																																																																																		2						2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				1	2	3	1				3		20	50	2				1	2	3	1				3		20	50	2				1	2	3	1				3		20	50	2				1	2																3	1				3		0	50	2				1	2	001
H5854	009	0	1	01	01	H5854_009_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	009	0	1	01	01	H5854_009_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	009	0	1	01	01	H5854_009_0	7																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	010	0	1	02	01	H5854_010_0	7	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	010	0	1	02	01	H5854_010_0	7	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	010	0	1	02	01	H5854_010_0	7	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	011	0	1	02	01	H5854_011_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	011	0	1	02	01	H5854_011_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	011	0	1	02	01	H5854_011_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	018	0	1	02	01	H5854_018_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	018	0	1	02	01	H5854_018_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	018	0	1	02	01	H5854_018_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5883	001	1	1	02	01	H5883_001_1	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (1 per quad/tooth per 36 months), debridement (1 / 60 months),   Localized delivery of antimicrobial agents -1/tooth ; 3 /quad; 12 total per 12 months.   Dressing change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement. Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.  Implants Maintenance & Repair - once per tooth per 60 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	001	2	1	02	01	H5883_001_2	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (1 per quad/tooth per 36 months), debridement (1 / 60 months),   Localized delivery of antimicrobial agents -1/tooth ; 3 /quad; 12 total per 12 months.   Dressing change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement. Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.  Implants Maintenance & Repair - once per tooth per 60 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	001	3	1	02	01	H5883_001_3	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (1 per quad/tooth per 36 months), debridement (1 / 60 months),   Localized delivery of antimicrobial agents -1/tooth ; 3 /quad; 12 total per 12 months.   Dressing change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement. Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.  Implants Maintenance & Repair - once per tooth per 60 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	001	4	1	02	01	H5883_001_4	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (1 per quad/tooth per 36 months), debridement (1 / 60 months),   Localized delivery of antimicrobial agents -1/tooth ; 3 /quad; 12 total per 12 months.   Dressing change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement. Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.  Implants Maintenance & Repair - once per tooth per 60 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	001	5	1	02	01	H5883_001_5	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (1 per quad/tooth per 36 months), debridement (1 / 60 months),   Localized delivery of antimicrobial agents -1/tooth ; 3 /quad; 12 total per 12 months.   Dressing change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement. Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.  Implants Maintenance & Repair - once per tooth per 60 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	002	1	1	02	01	H5883_002_1	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 monthsDebridement once per 60 monthsLocalized delivery of antimicrobial agents 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	002	2	1	02	01	H5883_002_2	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 monthsDebridement once per 60 monthsLocalized delivery of antimicrobial agents 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	002	3	1	02	01	H5883_002_3	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 monthsDebridement once per 60 monthsLocalized delivery of antimicrobial agents 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	002	4	1	02	01	H5883_002_4	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 monthsDebridement once per 60 monthsLocalized delivery of antimicrobial agents 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	002	7	1	02	01	H5883_002_7	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 monthsDebridement once per 60 monthsLocalized delivery of antimicrobial agents 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	003	1	1	02	01	H5883_003_1	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays- once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.	1	25	25	25	2				2	2	3	2	1	6	Dentures (once per arch per 84 months, denture adjustment and repairs (once per tooth or arch per 84 months), denture reline/rebase (once per arch per 36 months)	1	25	25	25	2				2	2																3	2	1	6	Implants (once per tooth per lifetime), Implants maintenance and repair (once per tooth per 60 months)	1	25	25	25	2				2	2	3	2	1	6	Bridges- one per tooth every 60 months	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia (up to 5 units per date of service), consultation exams (3 per 12 months).	1	25	25	25	2				2	2	001
H5883	003	2	1	02	01	H5883_003_2	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays- once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.	1	25	25	25	2				2	2	3	2	1	6	Dentures (once per arch per 84 months, denture adjustment and repairs (once per tooth or arch per 84 months), denture reline/rebase (once per arch per 36 months)	1	25	25	25	2				2	2																3	2	1	6	Implants (once per tooth per lifetime), Implants maintenance and repair (once per tooth per 60 months)	1	25	25	25	2				2	2	3	2	1	6	Bridges- one per tooth every 60 months	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia (up to 5 units per date of service), consultation exams (3 per 12 months).	1	25	25	25	2				2	2	001
H5883	003	3	1	02	01	H5883_003_3	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays- once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.	1	25	25	25	2				2	2	3	2	1	6	Dentures (once per arch per 84 months, denture adjustment and repairs (once per tooth or arch per 84 months), denture reline/rebase (once per arch per 36 months)	1	25	25	25	2				2	2																3	2	1	6	Implants (once per tooth per lifetime), Implants maintenance and repair (once per tooth per 60 months)	1	25	25	25	2				2	2	3	2	1	6	Bridges- one per tooth every 60 months	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia (up to 5 units per date of service), consultation exams (3 per 12 months).	1	25	25	25	2				2	2	001
H5883	003	4	1	02	01	H5883_003_4	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays- once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.	1	25	25	25	2				2	2	3	2	1	6	Dentures (once per arch per 84 months, denture adjustment and repairs (once per tooth or arch per 84 months), denture reline/rebase (once per arch per 36 months)	1	25	25	25	2				2	2																3	2	1	6	Implants (once per tooth per lifetime), Implants maintenance and repair (once per tooth per 60 months)	1	25	25	25	2				2	2	3	2	1	6	Bridges- one per tooth every 60 months	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia (up to 5 units per date of service), consultation exams (3 per 12 months).	1	25	25	25	2				2	2	001
H5883	003	5	1	02	01	H5883_003_5	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays- once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change.	1	25	25	25	2				2	2	3	2	1	6	Dentures (once per arch per 84 months, denture adjustment and repairs (once per tooth or arch per 84 months), denture reline/rebase (once per arch per 36 months)	1	25	25	25	2				2	2																3	2	1	6	Implants (once per tooth per lifetime), Implants maintenance and repair (once per tooth per 60 months)	1	25	25	25	2				2	2	3	2	1	6	Bridges- one per tooth every 60 months	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia (up to 5 units per date of service), consultation exams (3 per 12 months).	1	25	25	25	2				2	2	001
H5883	007	0	1	01	01	H5883_007_0	9								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - 1/ quad/tooth per 36 monthsDebridement - 1/ 60 monthsLocalized delivery of antimicrobial agents - 1/ tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	012	1	1	02	01	H5883_012_1	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - 1/quad/tooth per 36 monthsDebridement - 1/60 monthsLocalized delivery of antimicrobial agents - 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	012	2	1	02	01	H5883_012_2	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - 1/quad/tooth per 36 monthsDebridement - 1/60 monthsLocalized delivery of antimicrobial agents - 1 per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	014	1	1	02	01	H5883_014_1	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 months Debridement 1 per 60 months Localized delivery of antimicrobial agents: once per tooth/3 per quadrant/ 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	014	2	1	02	01	H5883_014_2	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 months Debridement 1 per 60 months Localized delivery of antimicrobial agents: once per tooth/3 per quadrant/ 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	014	3	1	02	01	H5883_014_3	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 months Debridement 1 per 60 months Localized delivery of antimicrobial agents: once per tooth/3 per quadrant/ 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	014	4	1	02	01	H5883_014_4	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 months Debridement 1 per 60 months Localized delivery of antimicrobial agents: once per tooth/3 per quadrant/ 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	014	5	1	02	01	H5883_014_5	10								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery 1 per quad/tooth per 36 months Debridement 1 per 60 months Localized delivery of antimicrobial agents: once per tooth/3 per quadrant/ 12 total per 12 monthsDressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5883	015	0	1	01	01	H5883_015_0	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - 1 / quad/tooth per 36 months Debridement - 1/ 60 months Localized delivery of antimicrobial agents -1/ tooth / 3 per quadrant / 12 total per 12 months Dressing Change as needed	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetimeImplants Maintenance & Repair - once per tooth per 60 months	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H5945	001	0	1	01	01	H5945_001_0	5	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H5945	002	0	1	01	01	H5945_002_0	4	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H5945	013	0	1	01	01	H5945_013_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				2				2	2																																																													001
H5945	014	0	1	01	01	H5945_014_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				2				2	2																																																													001
H5945	016	0	1	01	01	H5945_016_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H5945	027	0	1	01	01	H5945_027_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H5945	032	0	1	01	01	H5945_032_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H6322	001	0	1	01	01	H6322_001_0	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	001	0	1	01	01	H6322_001_0	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	002	0	1	01	01	H6322_002_0	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	002	0	1	01	01	H6322_002_0	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	003	1	1	02	01	H6322_003_1	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	003	1	1	02	01	H6322_003_1	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	003	2	1	02	01	H6322_003_2	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	003	2	1	02	01	H6322_003_2	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6706	001	0	1	02	01	H6706_001_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H6723	001	1	1	01	01	H6723_001_1	6	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	001	2	1	01	01	H6723_001_2	7																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	001	3	1	01	01	H6723_001_3	7	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	002	1	1	01	01	H6723_002_1	5																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	002	2	1	01	01	H6723_002_2	5																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	002	3	1	01	01	H6723_002_3	5																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	003	1	1	01	01	H6723_003_1	5	2			2				2	1	1	2					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																															001
H6723	003	2	1	01	01	H6723_003_2	5																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	003	3	1	01	01	H6723_003_3	5																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	005	1	1	02	01	H6723_005_1	6	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	005	2	1	02	01	H6723_005_2	5	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	006	6	1	02	01	H6723_006_6	5	2			2				2	1	1	1	1		1	1	2		1	1		1000.00	3		2														2																																3	1				2				2				2	2																																														1	1					2					2																																																																																																											3	1				2				2				2	2																															001
H6723	006	7	1	02	01	H6723_006_7	5	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6874	001	0	1	04	01	H6874_001_0	9	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					2		3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6874	003	0	1	04	01	H6874_003_0	5	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					2		3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6910	001	0	1	01	01	H6910_001_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H6910	001	0	1	01	01	H6910_001_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H6910	004	0	1	01	01	H6910_004_0	4	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H6910	004	0	1	01	01	H6910_004_0	4	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H7063	001	0	1	04	01	H7063_001_0	7								2	2	2	2	2			2	2		2																																																																																																																2						2					2		3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2																															3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		1	50	50	50	2				2	2	001
H7063	007	0	1	04	01	H7063_007_0	8								2	2	2	2	2			2	2		2																																																																																																																2						2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																															3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2	001
H7093	001	0	1	04	01	H7093_001_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7093	001	0	1	04	01	H7093_001_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7093	001	0	1	04	01	H7093_001_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7093	002	0	1	04	01	H7093_002_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7093	002	0	1	04	01	H7093_002_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7093	002	0	1	04	01	H7093_002_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	002	0	1	01	01	H7220_002_0	4								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	002	0	1	01	01	H7220_002_0	4								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	004	0	1	02	01	H7220_004_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	004	0	1	02	01	H7220_004_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	1	1	01	01	H7220_009_1	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	1	1	01	01	H7220_009_1	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	2	1	01	01	H7220_009_2	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	2	1	01	01	H7220_009_2	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	3	1	01	01	H7220_009_3	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	3	1	01	01	H7220_009_3	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	010	0	1	01	01	H7220_010_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	010	0	1	01	01	H7220_010_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	011	0	1	02	01	H7220_011_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	011	0	1	02	01	H7220_011_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	012	0	1	01	01	H7220_012_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	012	0	1	01	01	H7220_012_0	5								2	2							2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7239	001	0	1	01	01	H7239_001_0	3	1	1	1	1	1	1	1	1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H7239	003	0	1	01	01	H7239_003_0	5	1	1	1	1	1	1	1	1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H7680	001	0	1	01	01	H7680_001_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H7680	002	0	1	01	01	H7680_002_0	4	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				2				2	2																																																													001
H7680	009	0	1	01	01	H7680_009_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				2				2	2																																																													001
H7680	011	0	1	01	01	H7680_011_0	3	1	1	1	1	1	1	1	1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H7680	012	0	1	01	01	H7680_012_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H7680	014	0	1	01	01	H7680_014_0	4	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H7680	015	0	1	01	01	H7680_015_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				1	100.00	100.00	100.00	2	2																																																													001
H7680	016	0	1	01	01	H7680_016_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				2				2	2																																																													001
H7680	018	0	1	01	01	H7680_018_0	3	1	1	1	1	1	1	1	1	1	1	1	1			1	1		1																																																																																																																																																																																																								3	2	2	3		2				2				2	2																																																													001
H7680	019	0	1	02	01	H7680_019_0	5	1	1	1	1	1	1	1	1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H7917	042	0	1	04	01	H7917_042_0	5																			1	1	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				1	2	3	1				2				2				2	2	1	1					2					2		3	1				1	20	20	20	2				1	2	3	2	1	6	1 per tooth per 60 months	1	20	20	20	2				1	2	3	2	1	1		1	20	20	20	2				1	2	3	2	1	6	1 per 60 months	1	20	20	20	2				1	2																3	2	1	6	Implant supported prothesis (limited to 1 per 60 months)Surgical placement of implant (1 per tooth per lifetime)	1	20	20	20	2				1	2	3	2	1	6	1 per 60 months	1	20	20	20	2				1	2	3	1				1	20	20	20	2				1	2																															001
H7917	043	0	1	04	01	H7917_043_0	5																			1	1	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				1	2	3	1				2				2				2	2	1	1					2					2		3	1				1	20	20	20	2				1	2	3	2	1	6	1 per tooth per 60 months	1	20	20	20	2				1	2	3	2	1	1		1	20	20	20	2				1	2	3	2	1	6	1 per 60 months	1	20	20	20	2				1	2																3	2	1	6	Implant supported prothesis (limited to 1 per 60 months)Surgical placement of implant (1 per tooth per lifetime)	1	20	20	20	2				1	2	3	2	1	6	1 per 60 months	1	20	20	20	2				1	2	3	1				1	20	20	20	2				1	2																															001
H8133	005	0	1	01	01	H8133_005_0	8								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8211	005	0	1	04	01	H8211_005_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8211	006	0	1	04	01	H8211_006_0	7	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8211	011	0	1	04	01	H8211_011_0	7	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8432	009	0	1	02	01	H8432_009_0	8	2	2	2		2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	009	0	1	02	01	H8432_009_0	8	2	2	2		2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	009	0	1	02	01	H8432_009_0	8	2	2	2		2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	010	0	1	02	01	H8432_010_0	7	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	010	0	1	02	01	H8432_010_0	7	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	010	0	1	02	01	H8432_010_0	7	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	011	0	1	02	01	H8432_011_0	8	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	011	0	1	02	01	H8432_011_0	8	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	011	0	1	02	01	H8432_011_0	8	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	036	0	1	02	01	H8432_036_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	036	0	1	02	01	H8432_036_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	036	0	1	02	01	H8432_036_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	040	0	1	01	01	H8432_040_0	8																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	040	0	1	01	01	H8432_040_0	8																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	040	0	1	01	01	H8432_040_0	8																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8552	029	0	1	04	01	H8552_029_0	8	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8552	029	0	1	04	01	H8552_029_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8552	029	0	1	04	01	H8552_029_0	8	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8554	004	0	1	01	01	H8554_004_0	9								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8604	011	0	1	04	01	H8604_011_0	6																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	014	1	1	04	01	H8604_014_1	7								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	014	2	1	04	01	H8604_014_2	7								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.One Crown per tooth every five years.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years.	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia  unlimited.  Other limits vary depending on service	1	50	50	50	2				2	2																															001
H8634	003	0	1	04	01	H8634_003_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	008	0	1	04	01	H8634_008_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	010	0	1	04	01	H8634_010_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	012	0	1	04	01	H8634_012_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	017	0	1	04	01	H8634_017_0	8																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	019	0	1	04	01	H8634_019_0	5								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	020	0	1	04	01	H8634_020_0	8								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8764	001	0	1	01	01	H8764_001_0	7																																																																																																																																		1	2		1000.00	3		2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endodontics Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	002	0	1	02	01	H8764_002_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endodontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	002	0	1	02	01	H8764_002_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endodontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	003	0	1	01	01	H8764_003_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endondontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	003	0	1	01	01	H8764_003_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endondontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	004	0	1	01	01	H8764_004_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endondontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	004	0	1	01	01	H8764_004_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endodontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	801	0	1	02	01	H8764_801_0	4																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	4	6	Endodontic Therapy limited to 1 per lifetime. Other Services available.	1	50	50	50	2				2	2	3	2	2	3		1	50	50	50	2				2	2	3	2	4	3		1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	2	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8768	010	0	1	04	01	H8768_010_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	011	0	1	04	01	H8768_011_0	6	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	013	0	1	04	01	H8768_013_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	014	0	1	04	01	H8768_014_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	016	0	1	04	01	H8768_016_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	017	1	1	04	01	H8768_017_1	7	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	017	2	1	04	01	H8768_017_2	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	017	3	1	04	01	H8768_017_3	7	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	022	0	1	04	01	H8768_022_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	023	0	1	04	01	H8768_023_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	026	0	1	04	01	H8768_026_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	037	1	1	04	01	H8768_037_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	037	2	1	04	01	H8768_037_2	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	038	1	1	04	01	H8768_038_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	038	2	1	04	01	H8768_038_2	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	040	0	1	04	01	H8768_040_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	042	0	1	04	01	H8768_042_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	050	0	1	04	01	H8768_050_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	052	1	1	04	01	H8768_052_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	052	2	1	04	01	H8768_052_2	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	055	1	1	04	01	H8768_055_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	055	2	1	04	01	H8768_055_2	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	056	1	1	04	01	H8768_056_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	056	2	1	04	01	H8768_056_2	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	057	1	1	04	01	H8768_057_1	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	057	2	1	04	01	H8768_057_2	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8768	059	0	1	04	01	H8768_059_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
H8783	001	0	1	04	01	H8783_001_0	10	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					2		3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H8783	002	0	1	04	01	H8783_002_0	12	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					2		3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H8832	001	0	1	04	01	H8832_001_0	11	2	2	2		2	2		2	2	2	2	2			2	2			1	2	1000.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				2				2				1	2	3	1				2				2				1	2	3	1				2				2				1	2	3	1				2				2				1	2																															3	1				2				2				1	2	3	1				2				2				1	2																															001
H8832	002	0	1	04	01	H8832_002_0	10																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H8849	001	0	1	02	01	H8849_001_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	001	0	1	02	01	H8849_001_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	001	0	1	02	01	H8849_001_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	003	0	1	02	01	H8849_003_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	003	0	1	02	01	H8849_003_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	003	0	1	02	01	H8849_003_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	005	0	1	02	01	H8849_005_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	005	0	1	02	01	H8849_005_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	005	0	1	02	01	H8849_005_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	006	0	1	02	01	H8849_006_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	006	0	1	02	01	H8849_006_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	006	0	1	02	01	H8849_006_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	009	0	1	02	01	H8849_009_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	009	0	1	02	01	H8849_009_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	009	0	1	02	01	H8849_009_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	013	0	1	02	01	H8849_013_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	013	0	1	02	01	H8849_013_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	013	0	1	02	01	H8849_013_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9003	001	0	1	02	01	H9003_001_0	9																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		10	50	3		0.00	25.00	2	1	001
H9003	006	0	1	02	01	H9003_006_0	9																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		10	50	3		0.00	25.00	2	1	001
H9003	008	0	1	02	01	H9003_008_0	8																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	1		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				3		10	50	3		0.00	25.00	1	2	001
H9003	009	0	1	02	01	H9003_009_0	10																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		10	50	3		0.00	25.00	2	1	001
H9047	013	0	2	01	01	H9047_013_0	7	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		0	60	2				2	2	001
H9047	013	0	2	01	01	H9047_013_0	7	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	033	0	1	01	01	H9047_033_0	6	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		0	60	2				2	2	001
H9047	033	0	1	01	01	H9047_033_0	6	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	035	0	1	02	01	H9047_035_0	5	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2																																														3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H9047	035	0	1	02	01	H9047_035_0	5	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2	3	1				1	50	50	50	2				2	2																															3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H9047	037	0	1	01	01	H9047_037_0	8	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		0	60	2				2	2	001
H9047	037	0	1	01	01	H9047_037_0	8	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	054	0	1	01	01	H9047_054_0	7	2		2					2	2			2			2			2	2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		0	60	2				2	2	001
H9047	054	0	1	01	01	H9047_054_0	7	2		2					2	2	2	2	2			2	2		2	2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	059	0	1	02	01	H9047_059_0	8	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2																																														3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H9047	059	0	1	02	01	H9047_059_0	8	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2	3	1				1	50	50	50	2				2	2																															3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H9047	062	0	1	02	01	H9047_062_0	8	2		2					2	2			2			2			2	2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2																																														3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H9047	062	0	1	02	01	H9047_062_0	8	2		2					2	2	2	2	2			2	2		2	2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2	3	1				1	50	50	50	2				2	2																															3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H9047	063	0	1	01	01	H9047_063_0	8	2		2					2	2			2			2			2	2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		0	60	2				2	2	001
H9047	063	0	1	01	01	H9047_063_0	8	2		2					2	2	2	2	2			2	2		2	2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	064	0	1	01	01	H9047_064_0	8	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		0	60	2				2	2	001
H9047	064	0	1	01	01	H9047_064_0	8	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	065	0	1	02	01	H9047_065_0	7	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2																																														3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				3		0	50	2				2	2	001
H9047	065	0	1	02	01	H9047_065_0	7	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2	3	1				1	50	50	50	2				2	2																															3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H9179	001	0	1	01	01	H9179_001_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	001	0	1	01	01	H9179_001_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9179	003	0	1	01	01	H9179_003_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	003	0	1	01	01	H9179_003_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9219	001	0	1	04	01	H9219_001_0	7	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9219	001	0	1	04	01	H9219_001_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9219	001	0	1	04	01	H9219_001_0	7	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9219	004	0	1	04	01	H9219_004_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9219	004	0	1	04	01	H9219_004_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9219	004	0	1	04	01	H9219_004_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	004	0	1	02	01	H9525_004_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	004	0	1	02	01	H9525_004_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	004	0	1	02	01	H9525_004_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	006	0	1	02	01	H9525_006_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	006	0	1	02	01	H9525_006_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	006	0	1	02	01	H9525_006_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	011	0	1	02	01	H9525_011_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	011	0	1	02	01	H9525_011_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	011	0	1	02	01	H9525_011_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	1	1	02	01	H9525_013_1	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	1	1	02	01	H9525_013_1	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	1	1	02	01	H9525_013_1	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	2	1	02	01	H9525_013_2	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	2	1	02	01	H9525_013_2	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	2	1	02	01	H9525_013_2	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	3	1	02	01	H9525_013_3	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	3	1	02	01	H9525_013_3	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	3	1	02	01	H9525_013_3	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	4	1	02	01	H9525_013_4	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	4	1	02	01	H9525_013_4	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	4	1	02	01	H9525_013_4	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	015	0	1	02	01	H9525_015_0	8	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	015	0	1	02	01	H9525_015_0	8	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	015	0	1	02	01	H9525_015_0	8	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	017	0	1	02	01	H9525_017_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	017	0	1	02	01	H9525_017_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	017	0	1	02	01	H9525_017_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9572	001	1	1	04	01	H9572_001_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months, repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	001
H9572	001	2	1	04	01	H9572_001_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months, repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	001
H9572	001	3	1	04	01	H9572_001_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months, repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	001
H9572	001	4	1	04	01	H9572_001_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months. Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months.Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months, repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	001
H9572	001	6	1	04	01	H9572_001_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months, repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	001
H9572	002	1	1	04	01	H9572_002_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months, repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	002	2	1	04	01	H9572_002_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	002	3	1	04	01	H9572_002_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	002	4	1	04	01	H9572_002_4	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	002	6	1	04	01	H9572_002_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months. Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months.Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	003	1	1	04	01	H9572_003_1	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	003	2	1	04	01	H9572_003_2	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	003	3	1	04	01	H9572_003_3	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.Implants Maintenance & Repair - once per tooth per 60 months.Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	003	4	1	04	01	H9572_003_4	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	003	6	1	04	01	H9572_003_6	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	004	1	1	04	01	H9572_004_1	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months.Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of service.Consultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	004	2	1	04	01	H9572_004_2	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months.Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of service.Consultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	004	3	1	04	01	H9572_004_3	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months.Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of service.Consultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	004	4	1	04	01	H9572_004_4	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months.Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of service.Consultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	004	6	1	04	01	H9572_004_6	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures  - once per arch per 84 months.Denture Adjustment and repairs - 1 per 84 months/per tooth or arch.  Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of service.Consultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	006	1	1	04	01	H9572_006_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	006	2	1	04	01	H9572_006_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service.Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	006	3	1	04	01	H9572_006_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	006	4	1	04	01	H9572_006_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime.Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	006	6	1	04	01	H9572_006_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery (once per quad/tooth per 36 months), debridement (1 per 60 months), antimicrobial agent delivery, dressing change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 months.  Denture Adjustment and repairs - 1 per 84 months per tooth or arch.  Not within 6 months of placement.  Denture Reline/rebase - once per arch per 36 months.	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	007	1	1	04	01	H9572_007_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - once per quad/tooth per 36 monthsDebridement - once per 60 monthsLocalized delivery of antimicrobial agents - once per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch. Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	007	2	1	04	01	H9572_007_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - once per quad/tooth per 36 monthsDebridement - once per 60 monthsLocalized delivery of antimicrobial agents - once per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch. Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	007	3	1	04	01	H9572_007_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - once per quad/tooth per 36 monthsDebridement - once per 60 monthsLocalized delivery of antimicrobial agents - once per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch. Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	007	4	1	04	01	H9572_007_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - once per quad/tooth per 36 monthsDebridement - once per 60 monthsLocalized delivery of antimicrobial agents - once per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch. Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9572	007	6	1	04	01	H9572_007_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - once per tooth per 84 months	1	25	25	25	2				2	2																3	2	1	6	Perio Surgery - once per quad/tooth per 36 monthsDebridement - once per 60 monthsLocalized delivery of antimicrobial agents - once per tooth / 3 per quadrant / 12 total per 12 monthsDressing Change	1	25	25	25	2				2	2	3	2	1	6	Dentures - once per arch per 84 monthsDenture Adjustment and repairs - 1 per 84 months/per tooth or arch. Not within 6 months of placement.Denture Reline/Rebase - once per arch per 36 months	1	25	25	25	2				2	2																3	2	1	6	Implants - once per tooth per lifetime. Implants Maintenance & Repair - once per tooth per 60 months. Anesthesia up to five units per date of service. Consultation Exams - 3 per 12 months.	1	25	25	25	2				2	2	3	2	1	6	Bridges - 1 per tooth every 60 months.  Repairs.	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia - up to 5 units per date of serviceConsultation Exams - 3 per 12 months	1	25	25	25	2				2	2	001
H9706	008	0	1	01	01	H9706_008_0	8								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H9706	009	0	1	01	01	H9706_009_0	8								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H9808	010	0	1	04	01	H9808_010_0	9	2	2	2	2	2														2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	See notes for specific coverage and frequencies	3		0	20	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	3		0	20	2				2	2	3	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2					2		3	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																3	2	2	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																3	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2	001
H9827	001	0	1	01	01	H9827_001_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9827	001	0	1	01	01	H9827_001_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9827	003	0	1	01	01	H9827_003_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes, unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9827	003	0	1	01	01	H9827_003_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9834	001	0	1	01	01	H9834_001_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	003	0	1	01	01	H9834_003_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	004	0	1	01	01	H9834_004_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	005	0	1	01	01	H9834_005_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	006	0	1	01	01	H9834_006_0	6	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
R2604	001	0	1	31	11	R2604_001_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R2604	003	0	1	31	11	R2604_003_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R2604	005	0	1	31	11	R2604_005_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R3444	009	0	1	31	11	R3444_009_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R3444	012	0	1	31	11	R3444_012_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R3444	024	0	1	31	11	R3444_024_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R4487	001	0	1	31	11	R4487_001_0	9	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R4487	001	0	1	31	11	R4487_001_0	9	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R4487	001	0	1	31	11	R4487_001_0	9	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R5342	002	0	1	31	11	R5342_002_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R5342	005	0	1	31	11	R5342_005_0	6	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R5941	013	0	1	31	11	R5941_013_0	11	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	013	0	1	31	11	R5941_013_0	11	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	013	0	1	31	11	R5941_013_0	11	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R5941	014	0	1	31	11	R5941_014_0	9	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	014	0	1	31	11	R5941_014_0	9	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	014	0	1	31	11	R5941_014_0	9	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R6694	006	0	1	31	11	R6694_006_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
R6801	009	0	1	31	11	R6801_009_0	9	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
R6801	012	0	1	31	11	R6801_012_0	6	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	3		0	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2	001
