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
H0028	017	0	1	01	01	H0028_017_0	3	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	021	0	1	01	01	H0028_021_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	053	3	1	01	01	H0028_053_3	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0107	003	0	1	04	01	H0107_003_0	6																																																																																																																																		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
H0107	004	0	1	04	01	H0107_004_0	6								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	6																			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
H0107	010	0	1	04	01	H0107_010_0	6																																																																																																																																		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
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	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	004	0	1	04	01	H0294_004_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	014	0	1	04	01	H0294_014_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	015	0	1	04	01	H0294_015_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	016	0	1	04	01	H0294_016_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	017	0	1	04	01	H0294_017_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	032	0	1	04	01	H0294_032_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	048	0	1	04	01	H0294_048_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0432	003	0	1	02	01	H0432_003_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0432	004	0	1	02	01	H0432_004_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0432	017	0	1	02	01	H0432_017_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0473	005	0	1	04	01	H0473_005_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0504	015	0	1	01	01	H0504_015_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	017	0	1	01	01	H0504_017_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	021	0	1	01	01	H0504_021_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	026	0	1	01	01	H0504_026_0	6																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	6																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	028	0	1	01	01	H0504_028_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	038	0	1	01	01	H0504_038_0	5																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	039	0	1	01	01	H0504_039_0	5	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	001
H0504	040	0	1	01	01	H0504_040_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	041	0	1	01	01	H0504_041_0	6	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	6	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	043	0	1	01	01	H0504_043_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	047	0	1	01	01	H0504_047_0	5	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	5	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	050	0	1	01	01	H0504_050_0	5	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 the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing – single radiographic image, bitewings – two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for nutritional counseling for control of dental disease, sealant – per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam – one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate) – indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy – anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy – anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture – maxillary covered once per plan year every 5 years, immediate denture – maxillary covered once per lifetime.	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	050	0	1	01	01	H0504_050_0	5	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 the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	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 range: No frequency limit for amalgam – 4 or more surfaces, primary or permanent, crown – resin-based composite (indirect) 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 the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture – per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic – cast high noble metal covered once every 5 years from last date of service (exact tooth).	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 range: No frequency limit for palliative treatment of dental pain – per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment – limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0524	003	0	1	01	01	H0524_003_0	4	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	008	0	1	01	01	H0524_008_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	013	0	1	01	01	H0524_013_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	015	0	1	01	01	H0524_015_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	031	0	1	01	01	H0524_031_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	032	0	1	01	01	H0524_032_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	033	0	1	01	01	H0524_033_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	034	0	1	01	01	H0524_034_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	035	0	1	01	01	H0524_035_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	036	0	1	01	01	H0524_036_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	037	0	1	01	01	H0524_037_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	038	0	1	01	01	H0524_038_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	039	0	1	01	01	H0524_039_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	040	0	1	01	01	H0524_040_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	041	0	1	01	01	H0524_041_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	042	0	1	01	01	H0524_042_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	043	0	1	01	01	H0524_043_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	046	0	1	01	01	H0524_046_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	051	0	1	01	01	H0524_051_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	054	0	1	01	01	H0524_054_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	059	0	1	01	01	H0524_059_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	060	0	1	01	01	H0524_060_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	061	0	1	01	01	H0524_061_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	062	0	1	01	01	H0524_062_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	063	0	1	01	01	H0524_063_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	064	0	1	01	01	H0524_064_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	065	0	1	01	01	H0524_065_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	078	0	1	01	01	H0524_078_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	081	0	1	01	01	H0524_081_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	082	0	1	01	01	H0524_082_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	083	0	1	01	01	H0524_083_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0543	035	0	1	02	01	H0543_035_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	086	0	1	02	01	H0543_086_0	4	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	121	0	1	02	01	H0543_121_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	140	0	1	02	01	H0543_140_0	4	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	145	0	1	02	01	H0543_145_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	152	0	1	02	01	H0543_152_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	188	0	1	02	01	H0543_188_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	189	0	1	02	01	H0543_189_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	193	0	1	02	01	H0543_193_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	204	0	1	02	01	H0543_204_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	214	0	1	02	01	H0543_214_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	222	0	1	02	01	H0543_222_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	225	0	1	02	01	H0543_225_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	232	0	1	02	01	H0543_232_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	236	0	1	02	01	H0543_236_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	237	0	1	02	01	H0543_237_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	238	0	1	02	01	H0543_238_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	251	0	1	02	01	H0543_251_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	258	0	1	02	01	H0543_258_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0544	002	0	1	02	01	H0544_002_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	010	0	1	02	01	H0544_010_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	058	0	1	02	01	H0544_058_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	061	0	1	02	01	H0544_061_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	063	0	1	02	01	H0544_063_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	066	0	1	02	01	H0544_066_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	069	0	1	02	01	H0544_069_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	9	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	007	0	1	01	01	H0571_007_0	10	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	010	0	1	01	01	H0571_010_0	9	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	011	0	1	01	01	H0571_011_0	10	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0609	012	0	1	02	01	H0609_012_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	026	0	1	02	01	H0609_026_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	036	1	1	02	01	H0609_036_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	036	2	1	02	01	H0609_036_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	040	0	1	02	01	H0609_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	042	0	1	02	01	H0609_042_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	051	0	1	02	01	H0609_051_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	054	0	1	02	01	H0609_054_0	4	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	055	0	1	02	01	H0609_055_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	058	0	1	02	01	H0609_058_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	059	0	1	02	01	H0609_059_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	060	0	1	02	01	H0609_060_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	062	0	1	02	01	H0609_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	066	0	1	02	01	H0609_066_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	067	0	1	02	01	H0609_067_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	068	0	1	02	01	H0609_068_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	072	0	1	02	01	H0609_072_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	077	0	1	02	01	H0609_077_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0630	013	0	1	01	01	H0630_013_0	5								2	2	2	2							2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	6								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	5								2	2	2	2							2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	5								2	2	2	2							2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	031	0	1	02	01	H0755_031_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	033	0	1	02	01	H0755_033_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	038	0	1	02	01	H0755_038_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	044	0	1	02	01	H0755_044_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	045	0	1	02	01	H0755_045_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1036	318	0	1	02	01	H1036_318_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	319	0	1	01	01	H1036_319_0	2	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	323	0	1	01	01	H1036_323_0	3	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	334	0	1	01	01	H1036_334_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1170	002	0	1	01	01	H1170_002_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	009	0	1	01	01	H1170_009_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	012	0	1	01	01	H1170_012_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	013	0	1	02	01	H1170_013_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	014	0	1	01	01	H1170_014_0	5	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	016	0	1	01	01	H1170_016_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	017	0	1	01	01	H1170_017_0	5	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown – permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1181	001	0		07	02	H1181_001_0	3																			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	9																																																																																																																																		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	Frequency of services: • Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	• Complete or immediate denture - 1 per 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	• Implants - one per 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H1230	001	0	1	01	01	H1230_001_0	3								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	3								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	3								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	3								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	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	005	0	1	04	01	H1278_005_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	010	0	1	04	01	H1278_010_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	013	0	1	04	01	H1278_013_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	014	0	1	04	01	H1278_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	015	0	1	04	01	H1278_015_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	016	0	1	04	01	H1278_016_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	020	0	1	04	01	H1278_020_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	021	0	1	04	01	H1278_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	024	0	1	04	01	H1278_024_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	025	0	1	04	01	H1278_025_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	026	0	1	04	01	H1278_026_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	027	0	1	04	01	H1278_027_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	028	0	1	04	01	H1278_028_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	029	0	1	04	01	H1278_029_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	030	0	1	04	01	H1278_030_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	032	0	1	04	01	H1278_032_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1350	032	0	1	01	01	H1350_032_0	7																																																																																																																																		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
H1350	033	0	1	01	01	H1350_033_0	7																																																																																																																																		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
H1350	034	0	1	01	01	H1350_034_0	7																																																																																																																																		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
H1350	035	0	1	01	01	H1350_035_0	7																																																																																																																																		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
H1350	036	0	1	01	01	H1350_036_0	7																																																																																																																																		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
H1350	037	0	1	01	01	H1350_037_0	8																																																																																																																																		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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H1607	015	0	1	04	01	H1607_015_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H1666	003	0	1	04	01	H1666_003_0	6																																																																																																																																		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
H1666	006	0	1	04	01	H1666_006_0	6																																																																																																																																		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
H1666	008	0	1	04	01	H1666_008_0	6																																																																																																																																		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
H1666	012	0	1	04	01	H1666_012_0	6																																																																																																																																		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
H1666	014	0	1	04	01	H1666_014_0	6																																																																																																																																		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
H1666	019	0	1	04	01	H1666_019_0	7								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	6																			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
H1666	023	0	1	04	01	H1666_023_0	7																																																																																																																																		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
H1846	005	0	1	04	01	H1846_005_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	005	0	1	04	01	H1846_005_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
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	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	007	0	1	04	01	H1846_007_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
H1889	013	0	1	04	01	H1889_013_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	015	0	1	04	01	H1889_015_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	016	0	1	04	01	H1889_016_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	017	0	1	04	01	H1889_017_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	020	0	1	04	01	H1889_020_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	025	0	1	04	01	H1889_025_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1961	020	0	1	02	01	H1961_020_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1961	023	0	1	02	01	H1961_023_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1961	025	0	1	02	01	H1961_025_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	010	0	1	04	01	H2001_010_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	019	0	1	04	01	H2001_019_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	023	0	1	04	01	H2001_023_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	055	0	1	04	01	H2001_055_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	070	0	1	04	01	H2001_070_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	083	1	1	04	01	H2001_083_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	083	2	1	04	01	H2001_083_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	087	0	1	04	01	H2001_087_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	090	0	1	04	01	H2001_090_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	094	0	1	04	01	H2001_094_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	095	0	1	04	01	H2001_095_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	097	0	1	04	01	H2001_097_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	098	0	1	04	01	H2001_098_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	103	0	1	04	01	H2001_103_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	104	0	1	04	01	H2001_104_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	108	0	1	04	01	H2001_108_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	110	0	1	04	01	H2001_110_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	116	0	1	04	01	H2001_116_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	117	0	1	04	01	H2001_117_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	119	0	1	04	01	H2001_119_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	123	0	1	04	01	H2001_123_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	127	0	1	04	01	H2001_127_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	128	0	1	04	01	H2001_128_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	131	0	1	04	01	H2001_131_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	132	0	1	04	01	H2001_132_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	133	0	1	04	01	H2001_133_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	135	0	1	04	01	H2001_135_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	137	0	1	04	01	H2001_137_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2172	001	0	1	02	01	H2172_001_0	5								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	5								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	4								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	4								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	3								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	005	0	1	01	01	H2172_005_0	3								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	4								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	4								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	4								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	4								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	4								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	4								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	4								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	4								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	5								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	5								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	020	0	1	02	01	H2172_020_0	4								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	020	0	1	02	01	H2172_020_0	4								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	021	0	1	02	01	H2172_021_0	5								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	021	0	1	02	01	H2172_021_0	5								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	022	0	1	02	01	H2172_022_0	5								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	022	0	1	02	01	H2172_022_0	5								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	023	0	1	02	01	H2172_023_0	5								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	023	0	1	02	01	H2172_023_0	5								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	024	0	1	02	01	H2172_024_0	4								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	024	0	1	02	01	H2172_024_0	4								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	025	0	1	01	01	H2172_025_0	5								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	025	0	1	01	01	H2172_025_0	5								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	026	0	1	01	01	H2172_026_0	5																																																																																																																																		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	026	0	1	01	01	H2172_026_0	5																																																																																																																																		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	027	0	1	02	01	H2172_027_0	4								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	027	0	1	02	01	H2172_027_0	4								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
H2256	001	1	1	01	01	H2256_001_1	9																			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	8																			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	9																			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	9																			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	9																			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	9																			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	7																			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	7																			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	9	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	8	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	8	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	7	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	7	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	9	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	9	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	9	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	9																			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	9	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	9	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	7																			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	7	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	7	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	7	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	2					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		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	2					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		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	6	2		2		2			2	2							2		2	2					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		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	6	2		2		2			2	2							2		2	2					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		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	2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	2					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		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	2					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		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	2					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		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	2					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		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	2					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		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	6	2		2		2			2								2			2					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		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	032	1	1	02	01	H2320_032_1	5	2		2		2			2								2			2					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		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	032	2	1	02	01	H2320_032_2	5	2		2		2			2								2			2					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		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	032	5	1	02	01	H2320_032_5	5	2		2		2			2								2			2					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		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	7								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	6								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	6								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	019	0	1	01	01	H2354_019_0	5								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	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	028	0	1	01	01	H2354_028_0	6								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	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	040	0	1	04	01	H2406_040_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	041	0	1	04	01	H2406_041_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	044	0	1	04	01	H2406_044_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	048	0	1	04	01	H2406_048_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	056	0	1	04	01	H2406_056_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	059	0	1	04	01	H2406_059_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	062	0	1	04	01	H2406_062_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	065	0	1	04	01	H2406_065_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	066	0	1	04	01	H2406_066_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	067	0	1	04	01	H2406_067_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	068	0	1	04	01	H2406_068_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	069	0	1	04	01	H2406_069_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	070	0	1	04	01	H2406_070_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	071	0	1	04	01	H2406_071_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	072	0	1	04	01	H2406_072_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	075	0	1	04	01	H2406_075_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	076	0	1	04	01	H2406_076_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	078	0	1	04	01	H2406_078_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	087	0	1	04	01	H2406_087_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	089	0	1	04	01	H2406_089_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	090	0	1	04	01	H2406_090_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	091	0	1	04	01	H2406_091_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	093	0	1	04	01	H2406_093_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	094	0	1	04	01	H2406_094_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	096	0	1	04	01	H2406_096_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	097	0	1	04	01	H2406_097_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	098	0	1	04	01	H2406_098_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	101	0	1	04	01	H2406_101_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	104	0	1	04	01	H2406_104_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	110	0	1	04	01	H2406_110_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	112	0	1	04	01	H2406_112_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	113	0	1	04	01	H2406_113_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	119	0	1	04	01	H2406_119_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2462	027	0	1	18	06	H2462_027_0	6																			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	8																			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
H2593	001	0	1	02	01	H2593_001_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H2593	005	0	1	02	01	H2593_005_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H2802	001	0	1	02	01	H2802_001_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	007	0	1	02	01	H2802_007_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	008	0	1	02	01	H2802_008_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	010	0	1	02	01	H2802_010_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	028	0	1	02	01	H2802_028_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	030	0	1	02	01	H2802_030_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	048	0	1	02	01	H2802_048_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	054	0	1	02	01	H2802_054_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	059	0	1	02	01	H2802_059_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	063	0	1	02	01	H2802_063_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	068	0	1	02	01	H2802_068_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	070	0	1	02	01	H2802_070_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	071	0	1	02	01	H2802_071_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	076	0	1	02	01	H2802_076_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3138	001	0	1	04	01	H3138_001_0	6								2			2							2																																																																																																																1	2	2	1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	6								2			2							2																																																																																																																1	2	2	1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	6								2			2							2																																																																																																																1	2	2	1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	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	048	0	1	01	01	H3152_048_0	4																																																																																																																																		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
H3152	082	0	1	01	01	H3152_082_0	3																																																																																																																																		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
H3152	098	0	1	01	01	H3152_098_0	3																																																																																																																																		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
H3204	001	0	1	01	01	H3204_001_0	5																																																																																																																																		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	5																																																																																																																																		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	017	0	1	01	01	H3204_017_0	6																																																																																																																																		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	3																																																																																																																																		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	048	0	1	01	01	H3312_048_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
H3312	062	0	1	01	01	H3312_062_0	3																																																																																																																																		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	3																																																																																																																																		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	074	0	1	01	01	H3312_074_0	3																																																																																																																																		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	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
H3312	082	0	1	01	01	H3312_082_0	3																																																																																																																																		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	097	0	1	01	01	H3312_097_0	3																																																																																																																																		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
H3335	015	0	1	04	01	H3335_015_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	018	0	1	04	01	H3335_018_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	038	0	1	04	01	H3335_038_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	043	0	1	04	01	H3335_043_0	7								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	044	0	1	04	01	H3335_044_0	7								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	053	0	1	04	01	H3335_053_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	055	0	1	04	01	H3335_055_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	061	0	1	04	01	H3335_061_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		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
H3335	062	0	1	04	01	H3335_062_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		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
H3351	006	0	1	02	01	H3351_006_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	007	0	1	02	01	H3351_007_0	7								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	022	0	1	01	01	H3351_022_0	7																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		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
H3351	023	0	1	01	01	H3351_023_0	7																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		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
H3379	001	0	1	02	01	H3379_001_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	043	0	1	02	01	H3379_043_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	053	0	1	02	01	H3379_053_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	054	0	1	02	01	H3379_054_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	056	0	1	02	01	H3379_056_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	059	0	1	02	01	H3379_059_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	001	0	1	04	01	H3418_001_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	002	0	1	04	01	H3418_002_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	004	0	1	04	01	H3418_004_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	008	0	1	04	01	H3418_008_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3443	005	0	1	01	01	H3443_005_0	11	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	024	0	1	02	01	H3447_024_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	033	0	1	02	01	H3447_033_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	037	0	1	02	01	H3447_037_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	038	1	1	02	01	H3447_038_1	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	038	2	1	02	01	H3447_038_2	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	042	1	1	02	01	H3447_042_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	049	0	1	02	01	H3447_049_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	050	0	1	02	01	H3447_050_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	051	0	1	02	01	H3447_051_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	052	0	1	02	01	H3447_052_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3447	056	0	1	02	01	H3447_056_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	056	0	1	02	01	H3447_056_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	056	0	1	02	01	H3447_056_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
H3528	011	1	1	02	01	H3528_011_1	13																																																																																																																																		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	13																																																																																																																																		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	13	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	13																																																																																																																																		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	13																																																																																																																																		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	13	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	13																			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	13																			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	13																			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	14																			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	14																			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	14																			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
H3533	027	0	1	01	01	H3533_027_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H3655	041	0	1	02	01	H3655_041_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3655	045	1	1	02	01	H3655_045_1	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3655	045	2	1	02	01	H3655_045_2	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3655	045	3	1	02	01	H3655_045_3	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H3655	045	4	1	02	01	H3655_045_4	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	6								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	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 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	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	050	0	1	01	01	H3660_050_0	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	052	1	1	01	01	H3660_052_1	6								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	6								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	6								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	5								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	057	0	1	01	01	H3660_057_0	6								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
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	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	018	1	1	01	01	H3668_018_1	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	018	2	1	01	01	H3668_018_2	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	018	2	1	01	01	H3668_018_2	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	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	8	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	8	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	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	020	0	1	01	01	H3668_020_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	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	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	025	0	1	01	01	H3668_025_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	026	0	1	01	01	H3668_026_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	026	0	1	01	01	H3668_026_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	029	0	1	01	01	H3668_029_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
H3668	029	0	1	01	01	H3668_029_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
H3672	013	0	1	01	01	H3672_013_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	014	0	1	01	01	H3672_014_0	4								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	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	021	0	1	01	01	H3672_021_0	4								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	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	024	0	1	01	01	H3672_024_0	4								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	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	017	0	1	02	01	H3805_017_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	032	0	1	02	01	H3805_032_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	033	0	1	02	01	H3805_033_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	034	0	1	02	01	H3805_034_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	037	0	1	02	01	H3805_037_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	039	1	1	02	01	H3805_039_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	040	0	1	02	01	H3805_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	043	0	1	02	01	H3805_043_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3815	001	0	1	01	01	H3815_001_0	7	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	7	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	7	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	7	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	7	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	7	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	7	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	7	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	7	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	7	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	7	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	6	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	7																			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	7	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	7	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	7	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	7	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	7	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	054	0	1	01	01	H3815_054_0	8	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	055	0	1	01	01	H3815_055_0	7	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				2				2	2																															3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	056	0	1	01	01	H3815_056_0	7	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				2				2	2																															3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																															001
H3822	001	0	1	01	01	H3822_001_0	6								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	6								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	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
H3828	001	0	1	04	01	H3828_001_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
H3890	001	0	1	04	01	H3890_001_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services: • Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	• Complete or immediate denture - 1 per 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	• Implants - one per 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
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	Frequency of services: • Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	• Complete or immediate denture - 1 per 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	• Implants - one per 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	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 details	2				1	50.00	50.00	50.00	1	2	001
H3890	005	0	1	04	01	H3890_005_0	10																																																																																																																																		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	Frequency of services: • Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	• Complete or immediate denture - 1 per 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	• Implants - one per 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	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
H3979	001	0	1	01	01	H3979_001_0	6																																																																																																																																		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	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	017	0	1	04	01	H4036_017_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	022	0	1	04	01	H4036_022_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	025	0	1	04	01	H4036_025_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	026	0	1	04	01	H4036_026_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	034	0	1	04	01	H4036_034_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	036	0	1	04	01	H4036_036_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	040	0	1	04	01	H4036_040_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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
H4141	022	0	1	01	01	H4141_022_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H4161	002	0	1	02	01	H4161_002_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	004	0	1	02	01	H4161_004_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	005	0	1	02	01	H4161_005_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	010	0	1	02	01	H4161_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	011	0	1	02	01	H4161_011_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	013	0	1	02	01	H4161_013_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	014	0	1	02	01	H4161_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	015	0	1	02	01	H4161_015_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	016	0	1	02	01	H4161_016_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4161	017	0	1	02	01	H4161_017_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4346	001	0	1	02	01	H4346_001_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4346	005	0	1	02	01	H4346_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4346	006	0	1	02	01	H4346_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	030	0	1	02	01	H4346_030_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	030	0	1	02	01	H4346_030_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	030	0	1	02	01	H4346_030_0	4	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	15																			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	15																			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	15																			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	15																			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	14	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	14	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
H4514	007	0	1	02	01	H4514_007_0	4	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	002	0	1	02	01	H4527_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	037	0	1	02	01	H4527_037_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	039	0	1	02	01	H4527_039_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	048	0	1	02	01	H4527_048_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	051	0	1	02	01	H4527_051_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	053	0	1	02	01	H4527_053_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4544	001	0	1	04	01	H4544_001_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	011	0	1	02	01	H4604_011_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	016	0	1	02	01	H4604_016_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	017	0	1	02	01	H4604_017_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	020	0	1	02	01	H4604_020_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	022	0	1	02	01	H4604_022_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	024	0	1	02	01	H4604_024_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	025	0	1	02	01	H4604_025_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4875	016	1	1	04	01	H4875_016_1	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	6	2		2		2			2								2			2					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		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	2					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		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	2					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		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	2					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		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	2					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		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	2					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		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			2					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		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			2					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		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			2					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		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	2					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		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	2					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		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	2					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		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	2					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		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	2					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		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	11	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	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	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	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	014	1	1	04	01	H4882_014_1	7	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	2	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	014	2	1	04	01	H4882_014_2	6	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	2	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	020	0	1	04	01	H4909_020_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H4961	001	0	1	04	01	H4961_001_0	7																			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	7																			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	8	2	2	2		2	2													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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	024	0	1	01	01	H5050_024_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	025	0	1	01	01	H5050_025_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	026	0	1	01	01	H5050_026_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	027	0	1	01	01	H5050_027_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	028	0	1	01	01	H5050_028_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	029	0	1	01	01	H5050_029_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	030	0	1	01	01	H5050_030_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	031	0	1	01	01	H5050_031_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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	032	0	1	01	01	H5050_032_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	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
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				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	002	0	1	02	01	H5211_002_0	10	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				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	003	0	1	02	01	H5211_003_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				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	004	0	1	02	01	H5211_004_0	11	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				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	010	0	1	01	01	H5211_010_0	11	2	1	1	2	1	2		2	2	2	2	2		2	2	2		2	2					2				2					2					2																																3	1				1	50	50	50	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				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	5	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				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				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
H5215	005	0	1	04	01	H5215_005_0	5	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				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				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
H5215	008	0	1	04	01	H5215_008_0	5	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				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				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
H5215	009	0	1	04	01	H5215_009_0	5	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				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				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
H5215	012	0	1	04	01	H5215_012_0	5	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				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				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
H5216	013	0	1	04	01	H5216_013_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	017	0	1	04	01	H5216_017_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	019	0	1	04	01	H5216_019_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	023	0	1	04	01	H5216_023_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	027	0	1	04	01	H5216_027_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	034	0	1	04	01	H5216_034_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	037	0	1	04	01	H5216_037_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	063	0	1	04	01	H5216_063_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	064	0	1	04	01	H5216_064_0	5	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	073	0	1	04	01	H5216_073_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	078	1	1	04	01	H5216_078_1	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	078	6	1	04	01	H5216_078_6	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	089	0	1	04	01	H5216_089_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	092	0	1	04	01	H5216_092_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	100	0	1	04	01	H5216_100_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	116	0	1	04	01	H5216_116_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	138	0	1	04	01	H5216_138_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	144	0	1	04	01	H5216_144_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	154	0	1	04	01	H5216_154_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	168	0	1	04	01	H5216_168_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	192	0	1	04	01	H5216_192_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	194	0	1	04	01	H5216_194_0	2	2	2	2	2	2		2	2	2									2	2					2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	2						2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	211	0	1	04	01	H5216_211_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	234	0	1	04	01	H5216_234_0	2	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	286	0	1	04	01	H5216_286_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	289	0	1	04	01	H5216_289_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	308	0	1	04	01	H5216_308_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	309	0	1	04	01	H5216_309_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	310	0	1	04	01	H5216_310_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	322	0	1	04	01	H5216_322_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	343	0	1	04	01	H5216_343_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	345	0	1	04	01	H5216_345_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	359	0	1	04	01	H5216_359_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	376	0	1	04	01	H5216_376_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	379	0	1	04	01	H5216_379_0	2	2	2	2	2	2		2	2	2									2	1	2	750.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	383	0	1	04	01	H5216_383_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	389	0	1	04	01	H5216_389_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	395	0	1	04	01	H5216_395_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	406	0	1	04	01	H5216_406_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	429	0	1	04	01	H5216_429_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	430	0	1	04	01	H5216_430_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	433	0	1	04	01	H5216_433_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	442	0	1	04	01	H5216_442_0	2	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	461	0	1	04	01	H5216_461_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	464	0	1	04	01	H5216_464_0	4	2	2	2	2	2		2	2	2									2	2					2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	2						2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	465	0	1	04	01	H5216_465_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	466	0	1	04	01	H5216_466_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5253	034	0	1	02	01	H5253_034_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	035	0	1	02	01	H5253_035_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	039	0	1	02	01	H5253_039_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	040	0	1	02	01	H5253_040_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	062	0	1	02	01	H5253_062_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	072	0	1	02	01	H5253_072_0	7	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	097	0	1	02	01	H5253_097_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	099	0	1	02	01	H5253_099_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	103	0	1	02	01	H5253_103_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	108	2	1	02	01	H5253_108_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	110	0	1	02	01	H5253_110_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	119	0	1	02	01	H5253_119_0	4	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	120	0	1	02	01	H5253_120_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	125	1	1	02	01	H5253_125_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	127	0	1	02	01	H5253_127_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	135	0	1	02	01	H5253_135_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	142	0	1	02	01	H5253_142_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	144	1	1	02	01	H5253_144_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	144	2	1	02	01	H5253_144_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	154	0	1	02	01	H5253_154_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	155	0	1	02	01	H5253_155_0	7	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	157	1	1	02	01	H5253_157_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	157	2	1	02	01	H5253_157_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	159	0	1	02	01	H5253_159_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	161	0	1	02	01	H5253_161_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	162	1	1	02	01	H5253_162_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	162	2	1	02	01	H5253_162_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	169	0	1	02	01	H5253_169_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	173	0	1	02	01	H5253_173_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	175	0	1	02	01	H5253_175_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	176	0	1	02	01	H5253_176_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	179	0	1	02	01	H5253_179_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	180	0	1	02	01	H5253_180_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	182	0	1	02	01	H5253_182_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	183	0	1	02	01	H5253_183_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	186	0	1	02	01	H5253_186_0	11	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	188	0	1	02	01	H5253_188_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	189	0	1	02	01	H5253_189_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	192	0	1	02	01	H5253_192_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	193	1	1	02	01	H5253_193_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	195	0	1	02	01	H5253_195_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	197	0	1	02	01	H5253_197_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	198	0	1	02	01	H5253_198_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	202	0	1	02	01	H5253_202_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	207	0	1	02	01	H5253_207_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	208	0	1	02	01	H5253_208_0	4	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	209	0	1	02	01	H5253_209_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5262	001	0	1	01	01	H5262_001_0	4	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	4	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	3	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	3	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	4	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	4	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	3	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	3	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	4	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	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	032	0	1	01	01	H5262_032_0	4	2	2			2														1		1000.00	3		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																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				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				2				2				2	2																3	1				2				2				2	2	001
H5262	033	0	1	01	01	H5262_033_0	4	2	2			2														1		1000.00	3		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																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				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				2				2				2	2																3	1				2				2				2	2	001
H5296	006	0	1	01	01	H5296_006_0	10	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	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
H5322	040	0	1	02	01	H5322_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5322	047	1	1	02	01	H5322_047_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5322	047	2	1	02	01	H5322_047_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5386	003	0	1	01	01	H5386_003_0	7																			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	1	1	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	7																			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	8	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	8	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	006	0	1	01	01	H5386_006_0	8	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	005	0	1	01	01	H5425_005_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	006	0	1	01	01	H5425_006_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	007	0	1	01	01	H5425_007_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	008	0	1	01	01	H5425_008_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	009	0	1	01	01	H5425_009_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	034	0	1	01	01	H5425_034_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	082	0	1	01	01	H5425_082_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	086	0	1	01	01	H5425_086_0	8	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	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	092	0	1	01	01	H5425_092_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	096	0	1	01	01	H5425_096_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			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	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	134	0	1	01	01	H5425_134_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5472	003	0	1	02	01	H5472_003_0	10	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
H5472	010	0	1	02	01	H5472_010_0	7	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	077	0	1	04	01	H5521_077_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
H5521	120	0	1	04	01	H5521_120_0	3																																																																																																																																		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	3																																																																																																																																		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	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
H5521	124	0	1	04	01	H5521_124_0	3																																																																																																																																		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	215	0	1	04	01	H5521_215_0	3																																																																																																																																		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	277	0	1	04	01	H5521_277_0	3																																																																																																																																		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	392	0	1	04	01	H5521_392_0	3																																																																																																																																		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	457	0	1	04	01	H5521_457_0	3																																																																																																																																		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	512	0	1	04	01	H5521_512_0	3																																																																																																																																		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	3																																																																																																																																		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	521	0	1	04	01	H5521_521_0	3																																																																																																																																		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	536	0	1	04	01	H5521_536_0	3																																																																																																																																		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	3																																																																																																																																		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	661	0	1	04	01	H5521_661_0	3																																																																																																																																		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	662	0	1	04	01	H5521_662_0	3																																																																																																																																		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	664	0	1	04	01	H5521_664_0	3																																																																																																																																		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	665	0	1	04	01	H5521_665_0	3																																																																																																																																		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
H5525	004	0	1	04	01	H5525_004_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	005	0	1	04	01	H5525_005_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	006	0	1	04	01	H5525_006_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	008	0	1	04	01	H5525_008_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	030	0	1	04	01	H5525_030_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	035	0	1	04	01	H5525_035_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	042	0	1	04	01	H5525_042_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	049	0	1	04	01	H5525_049_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	051	2	1	04	01	H5525_051_2	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	065	0	1	04	01	H5525_065_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	085	1	1	04	01	H5525_085_1	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	085	2	1	04	01	H5525_085_2	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5591	018	0	1	02	01	H5591_018_0	5	2	2			1														1		1500.00	3		2				2					1	100100	50.00	50.00	50.00	2		3	2	1	3		2								2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															001
H5619	026	0	1	01	01	H5619_026_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	059	0	1	01	01	H5619_059_0	3	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	061	0	1	01	01	H5619_061_0	3	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	066	0	1	01	01	H5619_066_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	121	0	1	01	01	H5619_121_0	4	2	2	2	2	2		2	2	2									2	2					2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	2						2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	145	0	1	01	01	H5619_145_0	5	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	169	0	1	01	01	H5619_169_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	173	0	1	01	01	H5619_173_0	3	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	183	0	1	01	01	H5619_183_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5652	001	0	1	02	01	H5652_001_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	004	0	1	02	01	H5652_004_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	006	0	1	02	01	H5652_006_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	008	0	1	02	01	H5652_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5828	008	0	1	02	01	H5828_008_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H5828	013	0	1	02	01	H5828_013_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H5828	014	0	1	02	01	H5828_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H5828	015	0	1	02	01	H5828_015_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H5828	016	0	1	02	01	H5828_016_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H5828	017	0	1	02	01	H5828_017_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H5854	018	0	1	02	01	H5854_018_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	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	4	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	019	1	1	01	01	H5854_019_1	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	019	1	1	01	01	H5854_019_1	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	019	1	1	01	01	H5854_019_1	4																			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	019	2	1	01	01	H5854_019_2	5																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	019	2	1	01	01	H5854_019_2	5																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	019	2	1	01	01	H5854_019_2	5																			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	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	2	1	02	01	H5883_001_2	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	3	1	02	01	H5883_001_3	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	4	1	02	01	H5883_001_4	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	5	1	02	01	H5883_001_5	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	1	1	02	01	H5883_003_1	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	007	0	1	01	01	H5883_007_0	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5970	028	0	1	04	01	H5970_028_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	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	008	0	1	01	01	H6322_008_0	8								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	008	0	1	01	01	H6322_008_0	8								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
H6622	017	0	1	01	01	H6622_017_0	5	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	028	0	1	01	01	H6622_028_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H6622	055	0	1	01	01	H6622_055_0	2	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	090	0	1	01	01	H6622_090_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	095	0	1	01	01	H6622_095_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	097	0	1	01	01	H6622_097_0	2	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6706	001	0	1	02	01	H6706_001_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H6723	001	1	1	01	01	H6723_001_1	14	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	3	1	01	01	H6723_001_3	14	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	14																			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	14																			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	14	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	3	1	01	01	H6723_003_3	16	2			2				2	2	2	2					2		2	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	006	6	1	02	01	H6723_006_6	15	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	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
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	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																															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
H6988	006	0	1	02	01	H6988_006_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	006	0	1	02	01	H6988_006_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	006	0	1	02	01	H6988_006_0	5	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
H6988	007	0	1	02	01	H6988_007_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	007	0	1	02	01	H6988_007_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	007	0	1	02	01	H6988_007_0	5	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
H6988	008	0	1	02	01	H6988_008_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	008	0	1	02	01	H6988_008_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	008	0	1	02	01	H6988_008_0	4	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
H6988	009	0	1	02	01	H6988_009_0	7	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	009	0	1	02	01	H6988_009_0	7	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	009	0	1	02	01	H6988_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
H6988	010	0	1	02	01	H6988_010_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	010	0	1	02	01	H6988_010_0	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	010	0	1	02	01	H6988_010_0	5	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
H7063	001	0	1	04	01	H7063_001_0	3								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	3								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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H7220	004	0	1	02	01	H7220_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H7220	009	1	1	01	01	H7220_009_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H7220	009	2	1	01	01	H7220_009_2	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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													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
H7220	010	0	1	01	01	H7220_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H7617	003	0	1	04	01	H7617_003_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	007	0	1	04	01	H7617_007_0	4	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	024	0	1	04	01	H7617_024_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	027	0	1	04	01	H7617_027_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	044	0	1	04	01	H7617_044_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	046	0	1	04	01	H7617_046_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	049	0	1	04	01	H7617_049_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	094	0	1	04	01	H7617_094_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	096	0	1	04	01	H7617_096_0	1	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	100	0	1	04	01	H7617_100_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	101	0	1	04	01	H7617_101_0	1	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H8133	001	0	1	01	01	H8133_001_0	7																			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		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
H8133	005	0	1	01	01	H8133_005_0	6																																																																																																																																		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	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8145	055	0	1	09	04	H8145_055_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				2	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				2	2	3	2	2	1		1	0	0	0	2				2	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				2	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				2	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				2	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				2	2	001
H8145	163	0	1	09	04	H8145_163_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				2	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				2	2	3	2	2	1		1	0	0	0	2				2	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				2	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				2	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				2	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				2	2	001
H8211	006	0	1	04	01	H8211_006_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8211	009	0	1	04	01	H8211_009_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8211	011	0	1	04	01	H8211_011_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8432	009	0	1	01	01	H8432_009_0	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	009	0	1	01	01	H8432_009_0	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	009	0	1	01	01	H8432_009_0	4																			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	01	01	H8432_010_0	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	010	0	1	01	01	H8432_010_0	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	010	0	1	01	01	H8432_010_0	4																			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	01	01	H8432_011_0	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	011	0	1	01	01	H8432_011_0	4																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	011	0	1	01	01	H8432_011_0	4																			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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	02	01	H8432_040_0	7	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	040	0	1	02	01	H8432_040_0	7	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	040	0	1	02	01	H8432_040_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
H8547	001	0	1	01	01	H8547_001_0	6																																																																																																																																		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	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	5																																																																																																																																		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	5								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	5								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	015	0	1	04	01	H8604_015_0	6								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.	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
H8634	003	0	1	04	01	H8634_003_0	7								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	6								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	7																			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	7								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	019	0	1	04	01	H8634_019_0	6								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	022	0	1	04	01	H8634_022_0	9																																																																																																																																		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	023	0	1	04	01	H8634_023_0	9																																																																																																																																		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	025	0	1	04	01	H8634_025_0	8																																																																																																																																		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	026	0	1	04	01	H8634_026_0	6								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	027	0	1	04	01	H8634_027_0	7								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	028	0	1	04	01	H8634_028_0	7								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	031	0	1	04	01	H8634_031_0	7																																																																																																																																		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	033	0	1	04	01	H8634_033_0	7																																																																																																																																		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
H8764	001	0	1	01	01	H8764_001_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	5																			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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	5																			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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures are limited 1 every 60 months, denture adjustments are limited to 2 per arch per 12 months, denture repairs are limited to 2 per 60 months, rebase is limited to 1 per arch every 24 months, reline is limited to 1 per arch every 6 months.	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	1	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	6																			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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	6																			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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	3																			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	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once 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	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	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	009	0	1	04	01	H8768_009_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	010	0	1	04	01	H8768_010_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	011	0	1	04	01	H8768_011_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	013	0	1	04	01	H8768_013_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	016	0	1	04	01	H8768_016_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	017	1	1	04	01	H8768_017_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	017	2	1	04	01	H8768_017_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	022	0	1	04	01	H8768_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	023	0	1	04	01	H8768_023_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	026	0	1	04	01	H8768_026_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	034	0	1	04	01	H8768_034_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	037	1	1	04	01	H8768_037_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	037	2	1	04	01	H8768_037_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	040	0	1	04	01	H8768_040_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	046	0	1	04	01	H8768_046_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	055	1	1	04	01	H8768_055_1	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	055	2	1	04	01	H8768_055_2	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	058	0	1	04	01	H8768_058_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	059	0	1	04	01	H8768_059_0	3	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	061	0	1	04	01	H8768_061_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	062	0	1	04	01	H8768_062_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	063	0	1	04	01	H8768_063_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8832	001	0	1	04	01	H8832_001_0	7	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	7																			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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	003	0	1	02	01	H8849_003_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H8849	005	0	1	02	01	H8849_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H8849	006	0	1	02	01	H8849_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	009	0	1	02	01	H8849_009_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9003	001	0	1	02	01	H9003_001_0	4																			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		35	50	1	25.00	25.00	25.00	2	1	001
H9003	006	0	1	02	01	H9003_006_0	4																			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		35	50	1	25.00	25.00	25.00	2	1	001
H9003	008	0	1	02	01	H9003_008_0	4																			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		35	50	1	25.00	25.00	25.00	1	2	001
H9003	009	0	1	02	01	H9003_009_0	4																			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		35	50	1	25.00	25.00	25.00	2	1	001
H9047	013	0	2	01	01	H9047_013_0	9	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		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	013	0	2	01	01	H9047_013_0	9	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	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		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	033	0	1	01	01	H9047_033_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	035	0	1	02	01	H9047_035_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				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	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	037	0	1	01	01	H9047_037_0	10	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		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	037	0	1	01	01	H9047_037_0	10	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	10	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		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	054	0	1	01	01	H9047_054_0	10	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	063	0	1	01	01	H9047_063_0	11	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		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	063	0	1	01	01	H9047_063_0	11	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	10	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		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	064	0	1	01	01	H9047_064_0	10	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
H9065	002	0	1	02	01	H9065_002_0	5																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	002	0	1	02	01	H9065_002_0	5																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	002	0	1	02	01	H9065_002_0	5																			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
H9065	003	0	1	02	01	H9065_003_0	6																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	003	0	1	02	01	H9065_003_0	6																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	003	0	1	02	01	H9065_003_0	6																			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
H9065	008	0	1	01	01	H9065_008_0	5																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	008	0	1	01	01	H9065_008_0	5																			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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	008	0	1	01	01	H9065_008_0	5																			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
H9179	001	0	1	01	01	H9179_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
H9179	001	0	1	01	01	H9179_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
H9179	003	0	1	01	01	H9179_003_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
H9179	003	0	1	01	01	H9179_003_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
H9219	004	0	1	04	01	H9219_004_0	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	4	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	5	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9525	011	0	1	02	01	H9525_011_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9525	013	1	1	02	01	H9525_013_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9525	013	2	1	02	01	H9525_013_2	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9525	013	3	1	02	01	H9525_013_3	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9525	013	4	1	02	01	H9525_013_4	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
H9525	013	5	1	02	01	H9525_013_5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	5	1	02	01	H9525_013_5	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	5	1	02	01	H9525_013_5	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
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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	4	1	04	01	H9572_002_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	003	1	1	04	01	H9572_003_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	2	1	04	01	H9572_003_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	3	1	04	01	H9572_003_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	4	1	04	01	H9572_003_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	6	1	04	01	H9572_003_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	004	1	1	04	01	H9572_004_1	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	4	1	04	01	H9572_004_4	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	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 - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	1	1	04	01	H9572_007_1	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	2	1	04	01	H9572_007_2	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	3	1	04	01	H9572_007_3	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	4	1	04	01	H9572_007_4	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	6	1	04	01	H9572_007_6	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	008	0	1	04	01	H9572_008_0	7																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	Fillings, Crowns, Crown Repairs. Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2	3	2	1	6	Root Canals - once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Deep Cleaning - periodontal scaling and root planing.Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2	3	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	1	25	25	25	2				2	2																3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	009	0	1	04	01	H9572_009_0	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	010	0	1	04	01	H9572_010_0	7																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	Fillings, Crowns, Crown Repairs. Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2	3	2	1	6	Root Canals - once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Deep Cleaning - periodontal scaling and root planing.Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2	3	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	1	25	25	25	2				2	2																3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9686	008	0	1	01	01	H9686_008_0	10	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
H9706	001	0	1	01	01	H9706_001_0	6																																																																																																																																		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	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H9706	005	0	1	01	01	H9706_005_0	5																																																																																																																																		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	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H9706	008	0	1	01	01	H9706_008_0	6																			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		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
H9706	009	0	1	01	01	H9706_009_0	6								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	6	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	2				2				2	2	3	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	3	2	2	3		2				2				2	2																															1	2	2	1500.00	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	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	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	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
H9827	003	0	1	01	01	H9827_003_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
H9834	001	0	1	01	01	H9834_001_0	5	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	4	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	3	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	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	007	0	1	01	01	H9834_007_0	4	2	2			2														1		1000.00	3		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																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				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				2				2				2	2																3	1				2				2				2	2	001
R0110	005	0	1	31	11	R0110_005_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	008	0	1	31	11	R0110_008_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	012	0	1	31	11	R0110_012_0	2	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	020	0	1	31	11	R0110_020_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R2604	005	0	1	31	11	R2604_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R3444	009	0	1	31	11	R3444_009_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R3444	012	0	1	31	11	R3444_012_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R4182	003	0	1	31	11	R4182_003_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R4182	004	0	1	31	11	R4182_004_0	4	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R5361	002	0	1	31	11	R5361_002_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R5941	013	0	1	31	11	R5941_013_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
R5941	014	0	1	31	11	R5941_014_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	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	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
R5941	016	0	1	31	11	R5941_016_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	016	0	1	31	11	R5941_016_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	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	016	0	1	31	11	R5941_016_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
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	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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R6801	012	0	1	31	11	R6801_012_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.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R7220	001	0	1	31	11	R7220_001_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R7220	002	0	1	31	11	R7220_002_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
