pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_b16a_maxenr_mc_yn	pbp_b16a_maxenr_mc_amt	pbp_b16a_maxenr_mc_per	pbp_b16a_maxenr_mc_per_desc	pbp_b16a_coins_mc_yn	pbp_b16a_coins_mc_pct	pbp_b16a_coins_mc_pct_min	pbp_b16a_coins_mc_pct_max	pbp_b16a_copay_mc_yn	pbp_b16a_copay_mc_amt	pbp_b16a_copay_mc_amt_min	pbp_b16a_copay_mc_amt_max	pbp_b16a_ded_mc_yn	pbp_b16a_ded_mc_amt	pbp_b16a_auth_mc_yn	pbp_b16a_refer_mc_yn	pbp_b16b_maxplan_pv_yn	pbp_b16b_maxplan_pv_in_oon	pbp_b16b_maxplan_pv_amt	pbp_b16b_maxplan_pv_per	pbp_b16b_maxplan_pv_per_desc	pbp_b16b_maxenr_pv_yn	pbp_b16b_maxenr_pv_amt	pbp_b16b_maxenr_pv_per	pbp_b16b_maxenr_pv_per_desc	pbp_b16b_coins_ov_yn	pbp_b16b_coins_ov_svcs	pbp_b16b_coins_ov_pct	pbp_b16b_coins_ov_pct_min	pbp_b16b_coins_ov_pct_max	pbp_b16b_copay_ov_yn	pbp_b16b_copay_ov_svcs	pbp_b16b_copay_ov_amt	pbp_b16b_copay_ov_amt_min	pbp_b16b_copay_ov_amt_max	pbp_b16b_ded_pv_yn	pbp_b16b_ded_pv_amt	pbp_b16b_bendesc_oe_amo	pbp_b16b_bendesc_oe_lim	pbp_b16b_bendesc_oe_num	pbp_b16b_bendesc_oe_per	pbp_b16b_bendesc_oe_desc	pbp_b16b_coins_oe_yn	pbp_b16b_coins_oe_pct	pbp_b16b_coins_oe_pct_min	pbp_b16b_coins_oe_pct_max	pbp_b16b_copay_oe_yn	pbp_b16b_copay_oe_amt	pbp_b16b_copay_oe_amt_min	pbp_b16b_copay_oe_amt_max	pbp_b16b_auth_oe_yn	pbp_b16b_refer_oe_yn	pbp_b16b_bendesc_dx_amo	pbp_b16b_bendesc_dx_lim	pbp_b16b_bendesc_dx_num	pbp_b16b_bendesc_dx_per	pbp_b16b_bendesc_dx_desc	pbp_b16b_coins_dx_yn	pbp_b16b_coins_dx_pct	pbp_b16b_coins_dx_pct_min	pbp_b16b_coins_dx_pct_max	pbp_b16b_copay_dx_yn	pbp_b16b_copay_dx_amt	pbp_b16b_copay_dx_amt_min	pbp_b16b_copay_dx_amt_max	pbp_b16b_auth_dx_yn	pbp_b16b_refer_dx_yn	pbp_b16b_bendesc_ods_amo	pbp_b16b_bendesc_ods_lim	pbp_b16b_bendesc_ods_num	pbp_b16b_bendesc_ods_per	pbp_b16b_bendesc_ods_desc	pbp_b16b_coins_ods_yn	pbp_b16b_coins_ods_pct	pbp_b16b_coins_ods_pct_min	pbp_b16b_coins_ods_pct_max	pbp_b16b_copay_ods_yn	pbp_b16b_copay_ods_amt	pbp_b16b_copay_ods_amt_min	pbp_b16b_copay_ods_amt_max	pbp_b16b_auth_ods_yn	pbp_b16b_refer_ods_yn	pbp_b16b_bendesc_pc_amo	pbp_b16b_bendesc_pc_lim	pbp_b16b_bendesc_pc_num	pbp_b16b_bendesc_pc_per	pbp_b16b_bendesc_pc_desc	pbp_b16b_coins_pc_yn	pbp_b16b_coins_pc_pct	pbp_b16b_coins_pc_pct_min	pbp_b16b_coins_pc_pct_max	pbp_b16b_copay_pc_yn	pbp_b16b_copay_pc_amt	pbp_b16b_copay_pc_amt_min	pbp_b16b_copay_pc_amt_max	pbp_b16b_auth_pc_yn	pbp_b16b_refer_pc_yn	pbp_b16b_bendesc_ft_amo	pbp_b16b_bendesc_ft_lim	pbp_b16b_bendesc_ft_num	pbp_b16b_bendesc_ft_per	pbp_b16b_bendesc_ft_desc	pbp_b16b_coins_ft_yn	pbp_b16b_coins_ft_pct	pbp_b16b_coins_ft_pct_min	pbp_b16b_coins_ft_pct_max	pbp_b16b_copay_ft_yn	pbp_b16b_copay_ft_amt	pbp_b16b_copay_ft_amt_min	pbp_b16b_copay_ft_amt_max	pbp_b16b_auth_ft_yn	pbp_b16b_refer_ft_yn	pbp_b16b_bendesc_ops_amo	pbp_b16b_bendesc_ops_lim	pbp_b16b_bendesc_ops_num	pbp_b16b_bendesc_ops_per	pbp_b16b_bendesc_ops_desc	pbp_b16b_coins_ops_yn	pbp_b16b_coins_ops_pct	pbp_b16b_coins_ops_pct_min	pbp_b16b_coins_ops_pct_max	pbp_b16b_copay_ops_yn	pbp_b16b_copay_ops_amt	pbp_b16b_copay_ops_amt_min	pbp_b16b_copay_ops_amt_max	pbp_b16b_auth_ops_yn	pbp_b16b_refer_ops_yn	pbp_b16c_maxplan_cmp_yn	pbp_b16c_maxplan_cmp_type	pbp_b16c_maxplan_cmp_in_oon	pbp_b16c_maxplan_cmp_amt	pbp_b16c_maxplan_cmp_per	pbp_b16c_maxplan_cmp_per_desc	pbp_b16c_maxenr_cmp_yn	pbp_b16c_maxenr_cmp_type	pbp_b16c_maxenr_cmp_amt	pbp_b16c_maxenr_cmp_per	pbp_b16c_maxenr_cmp_per_desc	pbp_b16c_ded_cmp_yn	pbp_b16c_ded_cmp_amt	pbp_b16c_bendesc_rs_amo	pbp_b16c_bendesc_rs_lim	pbp_b16c_bendesc_rs_num	pbp_b16c_bendesc_rs_per	pbp_b16c_bendesc_rs_desc	pbp_b16c_coins_rs_yn	pbp_b16c_coins_rs_pct	pbp_b16c_coins_rs_pct_min	pbp_b16c_coins_rs_pct_max	pbp_b16c_copay_rs_yn	pbp_b16c_copay_rs_amt	pbp_b16c_copay_rs_amt_min	pbp_b16c_copay_rs_amt_max	pbp_b16c_auth_rs_yn	pbp_b16c_refer_rs_yn	pbp_b16c_bendesc_end_amo	pbp_b16c_bendesc_end_lim	pbp_b16c_bendesc_end_num	pbp_b16c_bendesc_end_per	pbp_b16c_bendesc_end_desc	pbp_b16c_coins_end_yn	pbp_b16c_coins_end_pct	pbp_b16c_coins_end_pct_min	pbp_b16c_coins_end_pct_max	pbp_b16c_copay_end_yn	pbp_b16c_copay_end_amt	pbp_b16c_copay_end_amt_min	pbp_b16c_copay_end_amt_max	pbp_b16c_auth_end_yn	pbp_b16c_refer_end_yn	pbp_b16c_bendesc_peri_amo	pbp_b16c_bendesc_peri_lim	pbp_b16c_bendesc_peri_num	pbp_b16c_bendesc_peri_per	pbp_b16c_bendesc_peri_desc	pbp_b16c_coins_peri_yn	pbp_b16c_coins_peri_pct	pbp_b16c_coins_peri_pct_min	pbp_b16c_coins_peri_pct_max	pbp_b16c_copay_peri_yn	pbp_b16c_copay_peri_amt	pbp_b16c_copay_peri_amt_min	pbp_b16c_copay_peri_amt_max	pbp_b16c_auth_peri_yn	pbp_b16c_refer_peri_yn	pbp_b16c_bendesc_prm_amo	pbp_b16c_bendesc_prm_lim	pbp_b16c_bendesc_prm_num	pbp_b16c_bendesc_prm_per	pbp_b16c_bendesc_prm_desc	pbp_b16c_coins_prm_yn	pbp_b16c_coins_prm_pct	pbp_b16c_coins_prm_pct_min	pbp_b16c_coins_prm_pct_max	pbp_b16c_copay_prm_yn	pbp_b16c_copay_prm_amt	pbp_b16c_copay_prm_amt_min	pbp_b16c_copay_prm_amt_max	pbp_b16c_auth_prm_yn	pbp_b16c_refer_prm_yn	pbp_b16c_bendesc_mxpr_amo	pbp_b16c_bendesc_mxpr_lim	pbp_b16c_bendesc_mxpr_num	pbp_b16c_bendesc_mxpr_per	pbp_b16c_bendesc_mxpr_desc	pbp_b16c_coins_mxpr_yn	pbp_b16c_coins_mxpr_pct	pbp_b16c_coins_mxpr_pct_min	pbp_b16c_coins_mxpr_pct_max	pbp_b16c_copay_mxpr_yn	pbp_b16c_copay_mxpr_amt	pbp_b16c_copay_mxpr_amt_min	pbp_b16c_copay_mxpr_amt_max	pbp_b16c_auth_mxpr_yn	pbp_b16c_refer_mxpr_yn	pbp_b16c_bendesc_impl_amo	pbp_b16c_bendesc_impl_lim	pbp_b16c_bendesc_impl_num	pbp_b16c_bendesc_impl_per	pbp_b16c_bendesc_impl_desc	pbp_b16c_coins_impl_yn	pbp_b16c_coins_impl_pct	pbp_b16c_coins_impl_pct_min	pbp_b16c_coins_impl_pct_max	pbp_b16c_copay_impl_yn	pbp_b16c_copay_impl_amt	pbp_b16c_copay_impl_amt_min	pbp_b16c_copay_impl_amt_max	pbp_b16c_auth_impl_yn	pbp_b16c_refer_impl_yn	pbp_b16c_bendesc_prf_amo	pbp_b16c_bendesc_prf_lim	pbp_b16c_bendesc_prf_num	pbp_b16c_bendesc_prf_per	pbp_b16c_bendesc_prf_desc	pbp_b16c_coins_prf_yn	pbp_b16c_coins_prf_pct	pbp_b16c_coins_prf_pct_min	pbp_b16c_coins_prf_pct_max	pbp_b16c_copay_prf_yn	pbp_b16c_copay_prf_amt	pbp_b16c_copay_prf_amt_min	pbp_b16c_copay_prf_amt_max	pbp_b16c_auth_prf_yn	pbp_b16c_refer_prf_yn	pbp_b16c_bendesc_omsg_amo	pbp_b16c_bendesc_omsg_lim	pbp_b16c_bendesc_omsg_num	pbp_b16c_bendesc_omsg_per	pbp_b16c_bendesc_omsg_desc	pbp_b16c_coins_omsg_yn	pbp_b16c_coins_omsg_pct	pbp_b16c_coins_omsg_pct_min	pbp_b16c_coins_omsg_pct_max	pbp_b16c_copay_omsg_yn	pbp_b16c_copay_omsg_amt	pbp_b16c_copay_omsg_amt_min	pbp_b16c_copay_omsg_amt_max	pbp_b16c_auth_omsg_yn	pbp_b16c_refer_omsg_yn	pbp_b16c_bendesc_orth_amo	pbp_b16c_bendesc_orth_lim	pbp_b16c_bendesc_orth_num	pbp_b16c_bendesc_orth_per	pbp_b16c_bendesc_orth_desc	pbp_b16c_coins_orth_yn	pbp_b16c_coins_orth_pct	pbp_b16c_coins_orth_pct_min	pbp_b16c_coins_orth_pct_max	pbp_b16c_copay_orth_yn	pbp_b16c_copay_orth_amt	pbp_b16c_copay_orth_amt_min	pbp_b16c_copay_orth_amt_max	pbp_b16c_auth_orth_yn	pbp_b16c_refer_orth_yn	pbp_b16c_bendesc_ags_amo	pbp_b16c_bendesc_ags_lim	pbp_b16c_bendesc_ags_num	pbp_b16c_bendesc_ags_per	pbp_b16c_bendesc_ags_desc	pbp_b16c_coins_ags_yn	pbp_b16c_coins_ags_pct	pbp_b16c_coins_ags_pct_min	pbp_b16c_coins_ags_pct_max	pbp_b16c_copay_ags_yn	pbp_b16c_copay_ags_amt	pbp_b16c_copay_ags_amt_min	pbp_b16c_copay_ags_amt_max	pbp_b16c_auth_ags_yn	pbp_b16c_refer_ags_yn
H0016	001	0	1	20	08	H0016_001_0	2																																																																																																																																																																																																																																																																																																		
H0016	003	0	1	20	08	H0016_003_0	2																																																																																																																																																																																																																																																																																																		
H0028	007	0	1	01	01	H0028_007_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H0028	014	0	1	01	01	H0028_014_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	015	0	1	02	01	H0028_015_0	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	016	0	1	02	01	H0028_016_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	017	0	1	01	01	H0028_017_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H0028	019	0	1	01	01	H0028_019_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	021	0	1	01	01	H0028_021_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H0028	024	0	1	01	01	H0028_024_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	028	0	1	01	01	H0028_028_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core 1/tooth/lifetime, crown recement, crown-1/tooth/lifetime, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	029	0	1	01	01	H0028_029_0	3	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	030	0	1	01	01	H0028_030_0	3	2				2				1	15.00	15.00	15.00	2		1	1	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	032	0	1	01	01	H0028_032_0	5	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	035	0	1	01	01	H0028_035_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	036	0	1	01	01	H0028_036_0	6	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	037	0	1	01	01	H0028_037_0	3	2				2				1	20.00	20.00	20.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	039	0	1	01	01	H0028_039_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	041	0	1	01	01	H0028_041_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	042	0	1	01	01	H0028_042_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	043	1	1	01	01	H0028_043_1	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	043	2	1	01	01	H0028_043_2	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	046	0	1	01	01	H0028_046_0	3	2				2				1	15.00	15.00	15.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	051	0	1	01	01	H0028_051_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	053	1	1	01	01	H0028_053_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	053	3	1	01	01	H0028_053_3	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H0028	054	1	1	02	01	H0028_054_1	3	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	054	2	1	02	01	H0028_054_2	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	055	0	1	02	01	H0028_055_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	056	0	1	02	01	H0028_056_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	059	0	1	01	01	H0028_059_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	060	0	1	01	01	H0028_060_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	062	0	1	01	01	H0028_062_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	063	0	1	01	01	H0028_063_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	065	0	1	01	01	H0028_065_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	066	0	1	02	01	H0028_066_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	067	0	1	02	01	H0028_067_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	070	0	1	01	01	H0028_070_0	2	2				2				1	15.00	15.00	15.00	2		1	1	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	072	0	1	01	01	H0028_072_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	074	1	1	01	01	H0028_074_1	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	074	2	1	01	01	H0028_074_2	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	076	0	1	01	01	H0028_076_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	077	0	1	01	01	H0028_077_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H0028	078	0	1	01	01	H0028_078_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	079	0	1	01	01	H0028_079_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	080	0	1	01	01	H0028_080_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H0028	081	1	1	01	01	H0028_081_1	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	081	2	1	01	01	H0028_081_2	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0028	082	0	1	01	01	H0028_082_0	3	2				2				1	35.00	35.00	35.00	2		1	1	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0028	801	0	1	01	01	H0028_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0028	802	0	1	01	01	H0028_802_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0028	804	0	1	01	01	H0028_804_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0028	805	0	1	01	01	H0028_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0029	007	0	1	02	01	H0029_007_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0029	008	0	1	02	01	H0029_008_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0029	009	0	1	02	01	H0029_009_0	7	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H0029	010	0	1	02	01	H0029_010_0	8	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0029	011	0	1	02	01	H0029_011_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0034	001	0	1	01	01	H0034_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0034	002	0	1	01	01	H0034_002_0	11	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0062	011	0	1	01	01	H0062_011_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0062	012	0	1	01	01	H0062_012_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0074	001	0	1	04	01	H0074_001_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0074	004	0	1	04	01	H0074_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0104	012	0	1	04	01	H0104_012_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0104	014	0	1	04	01	H0104_014_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	680.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0104	015	0	1	04	01	H0104_015_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0104	016	0	1	04	01	H0104_016_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	375.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																																																																																																																																			
H0104	801	0	1	04	01	H0104_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	802	0	1	04	01	H0104_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	804	0	1	04	01	H0104_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	805	0	1	04	01	H0104_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	806	0	1	04	01	H0104_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	807	0	1	04	01	H0104_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	808	0	1	04	01	H0104_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0104	809	0	1	04	01	H0104_809_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0105	001	0	1	20	08	H0105_001_0	2																																																																																																																																																																																																																																																																																																		
H0105	002	0	1	20	08	H0105_002_0	2																																																																																																																																																																																																																																																																																																		
H0107	003	0	1	04	01	H0107_003_0	6	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H0107	004	0	1	04	01	H0107_004_0	6	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0107	005	0	1	04	01	H0107_005_0	6	2				2				1	45.00	45.00	45.00	2		2	2																																																																																																																																																																																																																																																																																		
H0107	007	0	1	04	01	H0107_007_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H0107	010	0	1	04	01	H0107_010_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H0107	011	0	1	04	01	H0107_011_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H0107	801	0	1	04	01	H0107_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	802	0	1	04	01	H0107_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	803	0	1	04	01	H0107_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	804	0	1	04	01	H0107_804_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	805	0	1	04	01	H0107_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	806	0	1	04	01	H0107_806_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	807	0	1	04	01	H0107_807_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	808	0	1	04	01	H0107_808_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	809	0	1	04	01	H0107_809_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	810	0	1	04	01	H0107_810_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	811	0	1	04	01	H0107_811_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	812	0	1	04	01	H0107_812_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	813	0	1	04	01	H0107_813_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	814	0	1	04	01	H0107_814_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	815	0	1	04	01	H0107_815_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	816	0	1	04	01	H0107_816_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	817	0	1	04	01	H0107_817_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	818	0	1	04	01	H0107_818_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	819	0	1	04	01	H0107_819_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	820	0	1	04	01	H0107_820_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0107	821	0	1	04	01	H0107_821_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0111	001	0	1	04	01	H0111_001_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H0111	004	0	1	04	01	H0111_004_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0111	007	0	1	04	01	H0111_007_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0112	001	0	1	20	08	H0112_001_0	2																																																																																																																																																																																																																																																																																																		
H0112	002	0	1	20	08	H0112_002_0	2																																																																																																																																																																																																																																																																																																		
H0154	008	0	1	01	01	H0154_008_0	2	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	011	0	1	01	01	H0154_011_0	3	2				2				2				2		2	2	1		1300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	012	0	1	01	01	H0154_012_0	4	2				2				2				2		2	2	1		1050.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	015	1	1	01	01	H0154_015_1	3	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	015	2	1	01	01	H0154_015_2	3	2				2				2				2		2	2	1		700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	017	0	1	01	01	H0154_017_0	3	2				2				2				2		2	2	1		950.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	019	0	1	01	01	H0154_019_0	4	2				2				2				2		2	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	020	0	1	01	01	H0154_020_0	3	2				2				2				2		2	2	1		1650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0154	801	0	1	01	01	H0154_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0154	802	0	1	01	01	H0154_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0154	803	0	1	01	01	H0154_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0169	001	0	1	02	01	H0169_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0169	002	0	1	02	01	H0169_002_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0169	003	0	1	02	01	H0169_003_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0169	004	0	1	02	01	H0169_004_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0169	006	0	1	02	01	H0169_006_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0169	008	0	1	02	01	H0169_008_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0169	009	0	1	02	01	H0169_009_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0169	010	0	1	02	01	H0169_010_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0174	004	0	1	01	01	H0174_004_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	006	0	1	01	01	H0174_006_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	009	0	1	01	01	H0174_009_0	7	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	010	0	1	01	01	H0174_010_0	7	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	014	0	1	01	01	H0174_014_0	7	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	015	0	1	01	01	H0174_015_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	016	0	1	01	01	H0174_016_0	7	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	017	0	1	01	01	H0174_017_0	6	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	018	0	1	01	01	H0174_018_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	019	0	1	01	01	H0174_019_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	020	0	1	01	01	H0174_020_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	021	0	1	01	01	H0174_021_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0174	022	0	1	01	01	H0174_022_0	6	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	023	0	1	01	01	H0174_023_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	024	0	1	01	01	H0174_024_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	025	0	1	01	01	H0174_025_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0174	026	0	1	01	01	H0174_026_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0216	001	0	1	20	08	H0216_001_0	2																																																																																																																																																																																																																																																																																																		
H0216	002	0	1	20	08	H0216_002_0	2																																																																																																																																																																																																																																																																																																		
H0235	001	0	1	20	08	H0235_001_0	2																																																																																																																																																																																																																																																																																																		
H0235	002	0	1	20	08	H0235_002_0	2																																																																																																																																																																																																																																																																																																		
H0251	002	0	1	02	01	H0251_002_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0251	004	0	1	02	01	H0251_004_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0251	008	0	1	02	01	H0251_008_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0270	001	0	1	04	01	H0270_001_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0292	001	0	1	01	01	H0292_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0292	002	0	1	01	01	H0292_002_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0292	003	0	1	01	01	H0292_003_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0294	002	0	1	04	01	H0294_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0294	004	0	1	04	01	H0294_004_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0294	014	0	1	04	01	H0294_014_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0294	015	0	1	04	01	H0294_015_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0294	016	0	1	04	01	H0294_016_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0294	017	0	1	04	01	H0294_017_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0294	018	0	1	04	01	H0294_018_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0294	022	0	1	04	01	H0294_022_0	3	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0294	027	0	1	04	01	H0294_027_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0294	032	0	1	04	01	H0294_032_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0294	048	0	1	04	01	H0294_048_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0294	049	0	1	04	01	H0294_049_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0294	050	0	1	04	01	H0294_050_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0294	051	0	1	04	01	H0294_051_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0302	001	0	1	01	01	H0302_001_0	6	2				1	20	20	20	2				2		2	2	2					2				2					1	110110	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	10.00	10.00	10.00	2	2	1	2		3000.00	3		2					2		2	2	1	6	7-year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	one per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																2	2	1	6	One per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	006	0	1	01	01	H0302_006_0	7	2				2				1	10.00	10.00	10.00	2		2	2	2					2				2					1	110110	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	10.00	10.00	10.00	2	2	1	2		2000.00	3		2					2		2	2	1	6	7 year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																															2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	008	0	1	01	01	H0302_008_0	8	2				2				1	10.00	10.00	10.00	2		2	2	2					2				2					1	110110	10.00	10.00	10.00	2		2	2	2	6	Two evaluations per Calendar Year, including a maximum of one comprehensive evaluation per 36 monthsOne emergency or problem-focused exam per Calendar YearOne detailed and extensive oral evaluation	2								2	2	2	2	2	6	Bitewing X-rays Two per calendar yearPeriapical X-rays Four films per calendar yearFull Mouth or Panoramic X-rays One per five-year period	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	10.00	10.00	10.00	2	2	1	2		2000.00	3		2					2		2	2	1	6	7-year replacement limit	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime and one per tooth per 24 months for retreatment	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per quadrant per 24 months	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One Per 7 years	1	50	50	50	1	10.00	10.00	10.00	2	2																															2	2	1	6	One per 7 years and one per 12 months for re-cement or re-bond	1	50	50	50	1	10.00	10.00	10.00	2	2	2	2	1	6	One per tooth per lifetime	1	50	50	50	1	10.00	10.00	10.00	2	2																														
H0302	801	0	1	01	01	H0302_801_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0321	002	0	1	02	01	H0321_002_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0321	004	0	1	02	01	H0321_004_0	5	2				1	20	20	20	2				2		1	2	1		4500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0332	001	0	1	01	01	H0332_001_0	5	2				2				2				2		2	2	1		1500.00	3		2				2					2					1	25.00	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	1					2					2		2	2	1	3		2				2				2	2																																																																																											2	2	1	6	One per tooth per lifetime (D7140 and D7210)	2				2				2	2																2	2	1	3		2				2				2	2
H0332	004	0	1	02	01	H0332_004_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	3		2				2				2	2
H0332	009	0	1	01	01	H0332_009_0	7	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	3		2				2				2	2
H0332	801	0	1	01	01	H0332_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	803	0	1	01	01	H0332_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	804	0	1	01	01	H0332_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	805	0	1	01	01	H0332_805_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	806	0	1	01	01	H0332_806_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	807	0	1	01	01	H0332_807_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	808	0	1	01	01	H0332_808_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	809	0	1	01	01	H0332_809_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	810	0	1	01	01	H0332_810_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	811	0	1	01	01	H0332_811_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	812	0	1	01	01	H0332_812_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	813	0	1	01	01	H0332_813_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0332	814	0	1	01	01	H0332_814_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0342	001	0	1	04	01	H0342_001_0	9	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0342	801	0	1	04	01	H0342_801_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0342	802	0	1	04	01	H0342_802_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0342	803	0	1	04	01	H0342_803_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0342	804	0	1	04	01	H0342_804_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0351	038	0	1	01	01	H0351_038_0	6	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H0351	053	0	1	01	01	H0351_053_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0351	054	0	1	01	01	H0351_054_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H0351	057	0	1	01	01	H0351_057_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H0351	063	0	1	01	01	H0351_063_0	7	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0351	064	0	1	01	01	H0351_064_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0351	065	0	1	01	01	H0351_065_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0351	066	0	1	02	01	H0351_066_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0351	067	0	1	02	01	H0351_067_0	8	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0351	068	0	1	02	01	H0351_068_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0351	069	0	1	02	01	H0351_069_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2	2	2	1	6	every date of service to 5 years	1	40	40	40	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 5 plan years	1	40	40	40	2				1	2
H0351	070	0	1	02	01	H0351_070_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2	2	2	1	6	every date of service to 5 years	1	40	40	40	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 5 plan years	1	40	40	40	2				1	2
H0354	001	0	1	01	01	H0354_001_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				3		0.00	240.00	2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	620.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	575.00	2	2	2	1				2				3		25.00	450.00	2	2																2	1				2				3		0.00	950.00	2	2	2	1				2				3		0.00	525.00	2	2	2	1				2				3		0.00	455.00	2	2																2	1				2				3		0.00	260.00	2	2
H0354	027	0	1	01	01	H0354_027_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				3		0.00	240.00	2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	620.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	575.00	2	2	2	1				2				3		25.00	450.00	2	2																2	1				2				3		0.00	950.00	2	2	2	1				2				3		0.00	525.00	2	2	2	1				2				3		0.00	455.00	2	2																2	1				2				3		0.00	260.00	2	2
H0354	028	0	1	01	01	H0354_028_0	4	2				2				1	5.00	5.00	5.00	2		1	2	1		2900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0354	029	0	1	01	01	H0354_029_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0354	030	0	1	01	01	H0354_030_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0354	804	0	1	01	01	H0354_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0354	805	0	1	01	01	H0354_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0363	001	0	1	01	01	H0363_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0390	001	0	1	20	08	H0390_001_0	2																																																																																																																																																																																																																																																																																																		
H0390	002	0	1	20	08	H0390_002_0	2																																																																																																																																																																																																																																																																																																		
H0413	001	0	1	04	01	H0413_001_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0413	002	0	1	04	01	H0413_002_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0413	003	0	1	04	01	H0413_003_0	7	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H0421	001	0	1	04	01	H0421_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0423	001	0	1	01	01	H0423_001_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2						2					2		2	2	1	2		2				2				1	2	2	2	1	6	per 1 Lifetime Per patient, Same tooth	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	per patient- same tooth, every 96 months	2				2				1	2	2	2	1	6	per patient- same tooth, evert 60 months	2				2				1	2	2	2	1	6	One per lifetime, per patient, same quadrant.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2
H0423	004	0	1	01	01	H0423_004_0	7	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H0423	007	0	1	01	01	H0423_007_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2						2					2		2	2	1	2		2				2				1	2	2	2	1	6	per 1 Lifetime Per patient, Same tooth	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	per patient- same tooth, every 96 months	2				2				1	2	2	2	1	6	per patient- same tooth, evert 60 months	2				2				1	2	2	2	1	6	One per lifetime, per patient, same quadrant.	2				2				1	2	2	2	1	6	Please see notes below.	2				2				1	2	2	2	1	6	Please see noted below.	2				2				1	2
H0424	001	0	1	20	08	H0424_001_0	2																																																																																																																																																																																																																																																																																																		
H0424	002	0	1	20	08	H0424_002_0	2																																																																																																																																																																																																																																																																																																		
H0432	003	0	1	02	01	H0432_003_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0432	004	0	1	02	01	H0432_004_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0432	009	0	1	02	01	H0432_009_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0432	012	0	1	02	01	H0432_012_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0432	013	0	1	02	01	H0432_013_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0432	017	0	1	02	01	H0432_017_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0439	002	0	1	01	01	H0439_002_0	5	2				2				2				2		1	2	1		2650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	003	1	1	01	01	H0439_003_1	4	2				2				1	40.00	40.00	40.00	2		1	2	1		850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	003	2	1	01	01	H0439_003_2	4	2				2				1	50.00	50.00	50.00	2		1	2	1		550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	006	0	1	01	01	H0439_006_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1100.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	008	0	1	01	01	H0439_008_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	009	0	1	01	01	H0439_009_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	010	0	1	01	01	H0439_010_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	011	0	1	01	01	H0439_011_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	012	0	1	01	01	H0439_012_0	4	2				1	20	20	20	2				2		1	2	1		3250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	013	0	1	01	01	H0439_013_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	015	1	1	01	01	H0439_015_1	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	015	2	1	01	01	H0439_015_2	4	2				2				1	35.00	35.00	35.00	2		1	2	1		800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	016	0	1	01	01	H0439_016_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	017	0	1	01	01	H0439_017_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	018	0	1	01	01	H0439_018_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	019	0	1	01	01	H0439_019_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	020	0	1	01	01	H0439_020_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	021	0	1	01	01	H0439_021_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	022	0	1	01	01	H0439_022_0	4	2				2				2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	023	0	1	01	01	H0439_023_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	024	0	1	02	01	H0439_024_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0439	801	0	1	01	01	H0439_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0440	001	0	1	20	08	H0440_001_0	2																																																																																																																																																																																																																																																																																																		
H0440	002	0	1	20	08	H0440_002_0	2																																																																																																																																																																																																																																																																																																		
H0473	003	0	1	04	01	H0473_003_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0473	004	0	1	04	01	H0473_004_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H0473	005	0	1	04	01	H0473_005_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H0477	001	0	1	20	08	H0477_001_0	2																																																																																																																																																																																																																																																																																																		
H0477	002	0	1	20	08	H0477_002_0	2																																																																																																																																																																																																																																																																																																		
H0504	015	0	1	01	01	H0504_015_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	017	0	1	01	01	H0504_017_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	021	0	1	01	01	H0504_021_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	026	0	1	01	01	H0504_026_0	6	2				2				2				2		2	1																																																																																																																																																																																																																																																																																		
H0504	028	0	1	01	01	H0504_028_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	038	0	1	01	01	H0504_038_0	5	2				2				2				2		2	1																																																																																																																																																																																																																																																																																		
H0504	039	0	1	01	01	H0504_039_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	3		0	20	2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details	3		0	20	2				2	2	4	2	1	4		3		0	20	2				2	2	4	2	2	4		3		0	20	2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, caries preventive medicament application – per tooth covered twice every 12 months from last date of service, sealant – per tooth covered twice every 36 months (exact tooth) from last date of service.	3		0	20	2				2	2																																																																																																																																																																			
H0504	040	0	1	01	01	H0504_040_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	041	0	1	01	01	H0504_041_0	6	2				2				3		0.00	10.00	2		2	1	2					2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, caries preventive medicament application – per tooth covered twice every 12 months from last date of service, sealant – per tooth covered twice every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																			
H0504	043	0	1	01	01	H0504_043_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	047	0	1	01	01	H0504_047_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details	2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, caries preventive medicament application – per tooth covered twice every 12 months from last date of service, sealant – per tooth covered twice every 36 months (exact tooth) from last date of service.	2				2				2	2																																																																																																																																																																			
H0504	050	0	1	01	01	H0504_050_0	5	2				2				2				2		2	1	2					2				2					2					2		4	2	1	6	No frequency limit for limited oral evaluation – problem focused, periodic oral evaluation – established patient covered twice every 12 months from last date of service, comprehensive oral evaluation – new or established patient covered once every 36 months from last date of service.	2				3		0.00	16.00	2	2	4	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				3		0.00	10.00	2	2	4	1				2				3		0.00	15.00	2	2	4	2	2	3		2				2				2	2	4	2	1	4		2				1	5.00	5.00	5.00	2	2	4	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	80.00	2	2	2						2					2		4	2	1	6	Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	2				3		19.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		25.00	373.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		40.00	60.00	2	2	4	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		28.00	525.00	2	2																3													2	2	4	2	1	6	Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic – indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.	2				3		40.00	430.00	2	2	4	2	1	6	Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		23.00	80.00	2	2																4	1				2				3		0.00	80.00	2	2
H0504	803	0	1	01	01	H0504_803_0	3	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H0504	804	0	1	01	01	H0504_804_0	3	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H0504	805	0	1	01	01	H0504_805_0	3	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H0504	806	0	1	01	01	H0504_806_0	3	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H0523	022	0	1	01	01	H0523_022_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H0523	065	0	1	01	01	H0523_065_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	070	0	1	02	01	H0523_070_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	073	0	1	02	01	H0523_073_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	074	0	1	02	01	H0523_074_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	075	0	1	02	01	H0523_075_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	083	0	1	02	01	H0523_083_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	085	0	1	02	01	H0523_085_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	086	0	1	01	01	H0523_086_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	088	0	1	02	01	H0523_088_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	089	0	1	01	01	H0523_089_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	091	0	1	01	01	H0523_091_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	092	0	1	01	01	H0523_092_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0523	801	0	1	01	01	H0523_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0523	805	0	1	01	01	H0523_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0524	003	0	1	01	01	H0524_003_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	008	0	1	01	01	H0524_008_0	5	2				2				3		0.00	10.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	013	0	1	01	01	H0524_013_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	015	0	1	01	01	H0524_015_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	031	0	1	01	01	H0524_031_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	032	0	1	01	01	H0524_032_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	033	0	1	01	01	H0524_033_0	5	2				2				3		0.00	10.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	034	0	1	01	01	H0524_034_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	035	0	1	01	01	H0524_035_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	036	0	1	01	01	H0524_036_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	037	0	1	01	01	H0524_037_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	038	0	1	01	01	H0524_038_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	039	0	1	01	01	H0524_039_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	040	0	1	01	01	H0524_040_0	5	2				2				3		0.00	5.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	041	0	1	01	01	H0524_041_0	5	2				2				3		5.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	1	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	042	0	1	01	01	H0524_042_0	5	2				2				3		0.00	10.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	043	0	1	01	01	H0524_043_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													1	1	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	046	0	1	01	01	H0524_046_0	5	2				2				3		5.00	25.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													1	1	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	051	0	1	01	01	H0524_051_0	5	2				2				3		5.00	30.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													1	1	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	054	0	1	01	01	H0524_054_0	5	2				2				3		0.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	059	0	1	01	01	H0524_059_0	5	2				2				3		5.00	20.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	060	0	1	01	01	H0524_060_0	5	2				2				3		10.00	25.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	061	0	1	01	01	H0524_061_0	5	2				2				3		5.00	15.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	062	0	1	01	01	H0524_062_0	5	2				2				3		5.00	20.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	063	0	1	01	01	H0524_063_0	5	2				2				3		5.00	25.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	064	0	1	01	01	H0524_064_0	5	2				2				3		5.00	30.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	065	0	1	01	01	H0524_065_0	5	2				2				3		5.00	25.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	078	0	1	01	01	H0524_078_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	081	0	1	01	01	H0524_081_0	5	2				2				3		0.00	10.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	082	0	1	01	01	H0524_082_0	5	2				2				3		0.00	10.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	083	0	1	01	01	H0524_083_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								1	1	4	2	1	6	Two periapicals or one set of bitewing x-rays every calendar year. One comprehensive series of radiographic image or panoramic radiographic image every 2 calendar years. One 2D oral image every 3 years.	2								1	1	3													2	2	2	2	2	3		2								1	1	2	2	2	3		2								1	1	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	6	Periodontal scaling is covered once per quadrant every 2 calendar years. Scaling in the presence of inflammation and periodontal maintenance two every calendar year.	2				1	0.00	0.00	0.00	1	1	3													2	2																3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H0524	801	0	1	01	01	H0524_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	802	0	1	01	01	H0524_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	803	0	2	01	01	H0524_803_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	804	0	2	01	01	H0524_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	805	0	1	01	01	H0524_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	806	0	1	01	01	H0524_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	807	0	2	01	01	H0524_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0524	808	0	2	01	01	H0524_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0542	001	0	1	20	08	H0542_001_0	2																																																																																																																																																																																																																																																																																																		
H0542	002	0	1	20	08	H0542_002_0	2																																																																																																																																																																																																																																																																																																		
H0543	013	0	1	02	01	H0543_013_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	019	0	1	02	01	H0543_019_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	035	0	1	02	01	H0543_035_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	060	0	1	02	01	H0543_060_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	086	0	1	02	01	H0543_086_0	4	2				1	20	20	20	2				2		1	1																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H0543	121	0	1	02	01	H0543_121_0	3	2				1	20	20	20	2				2		1	1																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H0543	140	0	1	02	01	H0543_140_0	4	2				1	20	20	20	2				2		1	1																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H0543	145	0	1	02	01	H0543_145_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	151	0	1	02	01	H0543_151_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	152	0	1	02	01	H0543_152_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	166	0	1	02	01	H0543_166_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	168	0	1	02	01	H0543_168_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	169	0	1	02	01	H0543_169_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	170	0	1	02	01	H0543_170_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	188	0	1	02	01	H0543_188_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	189	0	1	02	01	H0543_189_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	191	0	1	02	01	H0543_191_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	193	0	1	02	01	H0543_193_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	204	0	1	02	01	H0543_204_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	214	0	1	02	01	H0543_214_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	217	0	1	02	01	H0543_217_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	218	0	1	02	01	H0543_218_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	219	0	1	02	01	H0543_219_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	220	0	1	02	01	H0543_220_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	221	0	1	02	01	H0543_221_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	222	0	1	02	01	H0543_222_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	225	0	1	02	01	H0543_225_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	226	0	1	02	01	H0543_226_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	232	0	1	02	01	H0543_232_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	236	0	1	02	01	H0543_236_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	237	0	1	02	01	H0543_237_0	10	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	238	0	1	02	01	H0543_238_0	10	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	239	0	1	01	01	H0543_239_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	240	0	1	01	01	H0543_240_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	241	0	1	01	01	H0543_241_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	242	0	1	01	01	H0543_242_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	246	0	1	01	01	H0543_246_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	249	0	1	02	01	H0543_249_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	251	0	1	02	01	H0543_251_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0543	254	0	1	02	01	H0543_254_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	255	0	1	02	01	H0543_255_0	13	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0543	258	0	1	02	01	H0543_258_0	3	2				1	20	20	20	2				2		1	1																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H0543	802	0	1	01	01	H0543_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	805	0	1	01	01	H0543_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	806	0	1	01	01	H0543_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0543	810	0	1	01	01	H0543_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0544	002	0	1	02	01	H0544_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	004	0	1	02	01	H0544_004_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	005	0	1	01	01	H0544_005_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	010	0	1	02	01	H0544_010_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	014	0	1	02	01	H0544_014_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	015	0	1	02	01	H0544_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	019	0	1	02	01	H0544_019_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	020	0	1	02	01	H0544_020_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0544	056	0	1	02	01	H0544_056_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	058	0	1	02	01	H0544_058_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	061	0	1	02	01	H0544_061_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	062	0	1	02	01	H0544_062_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	063	0	1	02	01	H0544_063_0	5	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	064	0	1	02	01	H0544_064_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	065	0	1	02	01	H0544_065_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	066	0	1	02	01	H0544_066_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	069	0	1	02	01	H0544_069_0	5	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	091	0	1	02	01	H0544_091_0	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H0544	095	0	1	02	01	H0544_095_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	096	0	1	02	01	H0544_096_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	098	0	1	02	01	H0544_098_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	108	0	1	02	01	H0544_108_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H0544	805	0	1	01	01	H0544_805_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0544	806	0	1	01	01	H0544_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0544	808	0	2	01	01	H0544_808_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0544	809	0	2	01	01	H0544_809_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0544	810	0	1	01	01	H0544_810_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0544	812	0	2	01	01	H0544_812_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0562	012	0	1	01	01	H0562_012_0	11	2				2				1	5.00	5.00	5.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	092	0	1	01	01	H0562_092_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	097	0	1	01	01	H0562_097_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	125	0	1	01	01	H0562_125_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	126	0	1	01	01	H0562_126_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	133	0	1	01	01	H0562_133_0	9	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	136	0	1	01	01	H0562_136_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	137	0	1	01	01	H0562_137_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	One every 2 calendar years	2				1	15.00	15.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	55.00	1	2	2						2					2		2	1				2				3		0.00	300.00	1	2	2	1				2				3		5.00	275.00	1	2	2	1				2				3		0.00	375.00	1	2	2	1				2				3		70.00	250.00	1	2																															2	1				2				3		0.00	225.00	1	2	2	1				2				3		0.00	70.00	1	2	2	1				2				3		0.00	2250.00	1	2	2	1				2				3		0.00	125.00	1	2
H0562	138	0	1	01	01	H0562_138_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		70.00	7		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0562	801	0	1	01	01	H0562_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0562	803	0	1	01	01	H0562_803_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0562	804	0	1	01	01	H0562_804_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0571	001	0	1	01	01	H0571_001_0	9	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2						2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0571	005	0	1	01	01	H0571_005_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H0571	007	0	1	01	01	H0571_007_0	10	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2						2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0571	010	0	1	01	01	H0571_010_0	9	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2						2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0571	011	0	1	01	01	H0571_011_0	10	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2																															2						2					2		3													2	2	3													2	2	4	2	2	3		2				3		0.00	55.00	2	2	3													2	2																															3													2	2	3													2	2	3													2	2	4	1				2				3		0.00	5.00	2	2
H0609	007	0	1	02	01	H0609_007_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	012	0	1	02	01	H0609_012_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	018	0	1	02	01	H0609_018_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	025	0	1	02	01	H0609_025_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	026	0	1	02	01	H0609_026_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	027	0	1	02	01	H0609_027_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	028	0	1	02	01	H0609_028_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	031	0	1	02	01	H0609_031_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	032	0	1	02	01	H0609_032_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	033	0	1	02	01	H0609_033_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	034	1	1	02	01	H0609_034_1	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	034	2	1	02	01	H0609_034_2	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	036	1	1	02	01	H0609_036_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	036	2	1	02	01	H0609_036_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	037	0	1	02	01	H0609_037_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	038	0	1	02	01	H0609_038_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	040	0	1	02	01	H0609_040_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	041	0	1	02	01	H0609_041_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	042	0	1	02	01	H0609_042_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	043	0	1	02	01	H0609_043_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	044	0	1	02	01	H0609_044_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	045	0	1	02	01	H0609_045_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	046	0	1	02	01	H0609_046_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	047	0	1	02	01	H0609_047_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	048	0	1	02	01	H0609_048_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	049	0	1	02	01	H0609_049_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	050	0	1	02	01	H0609_050_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	051	0	1	02	01	H0609_051_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	052	0	1	02	01	H0609_052_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0609	054	0	1	02	01	H0609_054_0	4	2				1	20	20	20	2				2		1	1																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H0609	055	0	1	02	01	H0609_055_0	3	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	056	0	1	02	01	H0609_056_0	3	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	058	0	1	02	01	H0609_058_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	059	0	1	02	01	H0609_059_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	060	0	1	02	01	H0609_060_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	061	0	1	02	01	H0609_061_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	062	0	1	02	01	H0609_062_0	5	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	063	0	1	02	01	H0609_063_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	065	0	1	02	01	H0609_065_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	066	0	1	02	01	H0609_066_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	067	0	1	02	01	H0609_067_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	068	0	1	02	01	H0609_068_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	070	0	1	02	01	H0609_070_0	3	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	071	0	1	02	01	H0609_071_0	4	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	072	0	1	02	01	H0609_072_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	073	0	1	02	01	H0609_073_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	075	0	1	02	01	H0609_075_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		6000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	076	0	1	02	01	H0609_076_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	077	0	1	02	01	H0609_077_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0609	078	0	1	02	01	H0609_078_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	079	0	1	02	01	H0609_079_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	080	0	1	02	01	H0609_080_0	5	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0609	801	0	1	01	01	H0609_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	804	0	1	01	01	H0609_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	805	0	1	01	01	H0609_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	806	0	2	01	01	H0609_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	807	0	1	01	01	H0609_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	808	0	1	01	01	H0609_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	809	0	1	01	01	H0609_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	810	0	1	01	01	H0609_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	811	0	1	01	01	H0609_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	812	0	1	01	01	H0609_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	813	0	1	01	01	H0609_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	814	0	1	01	01	H0609_814_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	815	0	1	01	01	H0609_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	817	0	1	01	01	H0609_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0609	822	0	1	01	01	H0609_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	823	0	1	01	01	H0609_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0609	824	0	1	01	01	H0609_824_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0613	001	0	1	20	08	H0613_001_0	2																																																																																																																																																																																																																																																																																																		
H0613	003	0	1	20	08	H0613_003_0	2																																																																																																																																																																																																																																																																																																		
H0624	001	0	1	02	01	H0624_001_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0624	006	0	1	02	01	H0624_006_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0628	001	0	1	02	01	H0628_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	003	0	1	02	01	H0628_003_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	005	0	1	02	01	H0628_005_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	007	0	1	02	01	H0628_007_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	008	0	1	02	01	H0628_008_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	010	0	1	02	01	H0628_010_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	012	0	1	01	01	H0628_012_0	2	2				1	20	20	20	2				2		1	2	1		2750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	013	0	1	01	01	H0628_013_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	017	0	1	02	01	H0628_017_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	018	0	1	01	01	H0628_018_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	019	0	1	02	01	H0628_019_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	021	0	1	02	01	H0628_021_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	024	0	1	02	01	H0628_024_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H0628	027	0	1	02	01	H0628_027_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	031	0	1	01	01	H0628_031_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	032	0	1	01	01	H0628_032_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	033	0	1	01	01	H0628_033_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	034	0	1	01	01	H0628_034_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	035	0	1	01	01	H0628_035_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	036	0	1	01	01	H0628_036_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	037	0	1	01	01	H0628_037_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	038	0	1	01	01	H0628_038_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	039	0	1	01	01	H0628_039_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H0628	040	0	1	01	01	H0628_040_0	2	2				1	20	20	20	2				2		1	2	1		1850.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	041	0	1	01	01	H0628_041_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0628	801	0	1	01	01	H0628_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0629	001	0	1	01	01	H0629_001_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0629	002	0	1	01	01	H0629_002_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0629	003	0	1	01	01	H0629_003_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0629	004	0	1	01	01	H0629_004_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H0630	013	0	1	01	01	H0630_013_0	5	2				2				1	20.00	20.00	20.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	014	0	1	01	01	H0630_014_0	5	2				2				1	5.00	5.00	5.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0630	015	0	1	02	01	H0630_015_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	3													2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	016	0	1	02	01	H0630_016_0	6	2				2				1	15.00	15.00	15.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	3													2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	017	0	1	01	01	H0630_017_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	020	0	1	01	01	H0630_020_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	021	0	1	02	01	H0630_021_0	5	2				2				1	20.00	20.00	20.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	3													2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	023	0	1	02	01	H0630_023_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	3													2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	024	0	1	01	01	H0630_024_0	5	2				1	20	20	20	2				2		2	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0630	025	0	1	02	01	H0630_025_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	1	0.00	0.00	0.00	2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	3													2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	1	0.00	0.00	0.00	2	2
H0630	027	0	1	01	01	H0630_027_0	5	2				1	20	20	20	2				2		2	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0630	805	0	2	01	01	H0630_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	806	0	2	01	01	H0630_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	807	0	1	01	01	H0630_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	808	0	1	01	01	H0630_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	811	0	2	01	01	H0630_811_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	812	0	2	01	01	H0630_812_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	813	0	1	01	01	H0630_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	814	0	1	01	01	H0630_814_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	817	0	2	01	01	H0630_817_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	818	0	2	01	01	H0630_818_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	819	0	1	01	01	H0630_819_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0630	820	0	1	01	01	H0630_820_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0672	005	0	1	01	01	H0672_005_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	006	0	1	01	01	H0672_006_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H0672	009	0	1	01	01	H0672_009_0	4	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	010	0	1	01	01	H0672_010_0	4	2				1	20	20	20	2				2		1	2	1		3350.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	013	0	1	01	01	H0672_013_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	015	0	1	01	01	H0672_015_0	4	2				2				2				2		1	2	1		2400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	016	0	1	01	01	H0672_016_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	017	0	1	01	01	H0672_017_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	018	0	1	01	01	H0672_018_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	024	0	1	01	01	H0672_024_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H0672	801	0	1	01	01	H0672_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0710	004	0	1	04	01	H0710_004_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	005	0	1	04	01	H0710_005_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	007	0	1	04	01	H0710_007_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	010	0	1	04	01	H0710_010_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	013	0	1	04	01	H0710_013_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	016	0	1	04	01	H0710_016_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	017	0	1	04	01	H0710_017_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	020	0	1	04	01	H0710_020_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	026	0	1	04	01	H0710_026_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	027	0	1	04	01	H0710_027_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	030	0	1	04	01	H0710_030_0	6	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	031	0	1	04	01	H0710_031_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	032	0	1	04	01	H0710_032_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	033	0	1	04	01	H0710_033_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	034	0	1	04	01	H0710_034_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	035	0	1	04	01	H0710_035_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	036	0	1	04	01	H0710_036_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	037	0	1	04	01	H0710_037_0	6	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	038	0	1	04	01	H0710_038_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	039	0	1	04	01	H0710_039_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	051	0	1	04	01	H0710_051_0	4	2				1	20	20	20	2				2		1	2	1	2	2400.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	052	0	1	04	01	H0710_052_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	053	0	1	04	01	H0710_053_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0710	057	0	1	04	01	H0710_057_0	6	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0710	801	0	1	04	01	H0710_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	802	0	1	04	01	H0710_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	803	0	1	04	01	H0710_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	804	0	2	04	01	H0710_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	805	0	2	04	01	H0710_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	806	0	2	04	01	H0710_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	807	0	1	04	01	H0710_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	808	0	1	04	01	H0710_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	809	0	1	04	01	H0710_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	810	0	1	04	01	H0710_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	811	0	1	04	01	H0710_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	812	0	2	04	01	H0710_812_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	813	0	2	04	01	H0710_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	814	0	2	04	01	H0710_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	815	0	1	04	01	H0710_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	816	0	1	04	01	H0710_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	817	0	1	04	01	H0710_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	818	0	1	04	01	H0710_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	819	0	1	04	01	H0710_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	820	0	1	04	01	H0710_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	821	0	1	04	01	H0710_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	822	0	1	04	01	H0710_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	823	0	1	04	01	H0710_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	824	0	2	04	01	H0710_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	825	0	1	04	01	H0710_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	826	0	1	04	01	H0710_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	827	0	1	04	01	H0710_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	829	0	1	04	01	H0710_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	830	0	1	04	01	H0710_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0710	831	0	1	04	01	H0710_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0712	005	0	1	02	01	H0712_005_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0712	019	0	1	02	01	H0712_019_0	10	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0712	029	0	1	01	01	H0712_029_0	8	2				1	20	20	20	2				2		1	2	1		70.00	7		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H0712	032	0	1	02	01	H0712_032_0	10	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0724	801	0	1	01	01	H0724_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0738	001	0	1	01	01	H0738_001_0	6	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		3600.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. Prior authorization required. 1 per tooth per lifetime. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H0738	002	0	1	01	01	H0738_002_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2000.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year.  Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H0755	030	0	1	02	01	H0755_030_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	031	0	1	02	01	H0755_031_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	032	0	1	02	01	H0755_032_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	033	0	1	02	01	H0755_033_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	037	0	1	02	01	H0755_037_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0755	038	0	1	02	01	H0755_038_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	044	0	1	02	01	H0755_044_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	045	0	1	02	01	H0755_045_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H0755	046	0	1	02	01	H0755_046_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H0755	810	0	1	01	01	H0755_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0755	811	0	1	01	01	H0755_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0755	812	0	1	01	01	H0755_812_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0755	813	0	1	01	01	H0755_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0755	814	0	1	01	01	H0755_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0755	815	0	1	01	01	H0755_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0764	001	0	1	04	01	H0764_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H0777	001	0	1	01	01	H0777_001_0	4	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	periodic oral eval 2 per yearlimited oral exam problem focused 2 per yearcomprehensive oral eval 1 per lifetimeComprehensive periodontal exam 1 per year	2				2				2	2	2	2	1	6	Intraoral- comprehensive series 1 per 3 yearsIntraoral periapical 4 per day and 12 per 12 monthsBitewings 2 per calendar yearpanoramic 1 per 3 yearscephalometric radiographic image (requires auth and must be used in conjunction with surgical condition)	2				2				1	2																2	2	2	3		2				2				2	2	2	2	1	5		2				2				2	2	2	2	2	6	two per tooth per lifetime	2				2				2	2	2						2					2		2	2	1	6	Amalgam 1 per year per toothResin based 1 per year per toothcrown - porcelain/ceramic 1 per 60 months recement not covered within 6months of placement	2				2				1	2	2	2	1	6	endodontics one per lifetime per toothapicoectomy one per lifetime per toothretreatment not within 24 months	2				2				2	2	2	2	1	6	periodontal scaling and root planning 1 per quadrant per 3 years scaling in presence of generalized moderate or severe gingival inflammation 2 per year gingivectomy or gingivoplasty -1 per 3 years	2				2				1	2	2	2	1	6	one every eighty four months	2				2				2	2																																														2	2	1	6	one coronectomy per tooth per lifetimeone alveoloplasty per patient per quadrant per six months	2				2				1	2																2	2	2	6	Palliative treatment-2 every calendar yearConsultations-1 every 6 monthsBehavior Management 1 per day per provider or location	2				2				1	2
H0783	004	0	1	01	01	H0783_004_0	2	2				2				1	20.00	20.00	20.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H0809	001	0	1	20	08	H0809_001_0	3																																																																																																																																																																																																																																																																																																		
H0809	002	0	1	20	08	H0809_002_0	3																																																																																																																																																																																																																																																																																																		
H0816	001	0	1	02	01	H0816_001_0	8	2				1	20	20	20	2				2		2	2	1		1250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2																2	2	3	3		2				2				2	2																															1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				3		0	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				3		20	50	2				2	2
H0816	002	0	1	02	01	H0816_002_0	8	2				1	20	20	20	2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2																2	2	3	3		2				2				2	2																															1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				3		0	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				3		20	50	2				2	2
H0819	001	0	1	20	08	H0819_001_0	2																																																																																																																																																																																																																																																																																																		
H0819	002	0	1	20	08	H0819_002_0	2																																																																																																																																																																																																																																																																																																		
H0839	001	0	1	20	08	H0839_001_0	2																																																																																																																																																																																																																																																																																																		
H0839	002	0	1	20	08	H0839_002_0	2																																																																																																																																																																																																																																																																																																		
H0870	001	0	1	20	08	H0870_001_0	2																																																																																																																																																																																																																																																																																																		
H0870	002	0	1	20	08	H0870_002_0	2																																																																																																																																																																																																																																																																																																		
H0885	001	0	1	04	01	H0885_001_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	002	0	1	04	01	H0885_002_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	003	0	1	04	01	H0885_003_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	005	0	1	04	01	H0885_005_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	006	0	1	04	01	H0885_006_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	007	0	1	04	01	H0885_007_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	008	0	1	04	01	H0885_008_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	009	0	1	04	01	H0885_009_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	2	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	3	3		2				2				2	2	2	2	2	4		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	2	6	See note regarding Restorative Services benefit limits	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2																																																													2	2	1	6	See note regarding Oral and Maxillofacial Surgery benefit limits	1	50	50	50	2				2	2																2	2	1	6	See note regarding Adjunctive General Services benefit limits	1	50	50	50	2				2	2
H0885	010	0	1	04	01	H0885_010_0	4	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	6	See Note regarding Oral Exams benefit limits.	2				2				2	2	2	2	1	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	2000.00	3		2					2		2	2	1	6	See note regarding Restorative Services benefit limits.	1	50	50	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	1	50	50	50	2				2	2	2	2	4	6	See note regarding Periodontics benefit limits.	1	50	50	50	2				2	2	2	2	1	6	See note regarding Prosthodontics benefit limits.	1	50	50	50	2				2	2																															2	2	1	6	See note regarding Prosthodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Oral and Maxillofacial Surgery benefit limits.	1	50	50	50	2				2	2																2	2	2	6	See note regarding Adjunctive General Services benefit limits.	1	50	50	50	2				2	2
H0885	011	0	1	04	01	H0885_011_0	4	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	6	See Note regarding Oral Exams benefit limits.	2				2				2	2	2	2	1	6	See note regarding Dental X-Rays benefit limits.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	2500.00	3		2					2		2	2	1	6	See note regarding Restorative Services benefit limits.	3		0	50	2				2	2	2	2	1	6	See note regarding Endodontics benefit limits.	2				2				2	2	2	2	4	6	See note regarding Periodontics benefit limits.	2				2				2	2	2	2	1	6	See note regarding Prosthodontics benefit limits.	1	50	50	50	2				2	2																															2	2	1	6	See note regarding Prosthodontics benefit limits.	1	50	50	50	2				2	2	2	2	2	6	See note regarding Oral and Maxillofacial Surgery benefit limits.	1	50	50	50	2				2	2																2	2	2	6	See note regarding Adjunctive General Services benefit limits.	1	50	50	50	2				2	2
H0885	801	0	1	04	01	H0885_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	802	0	1	04	01	H0885_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	805	0	1	04	01	H0885_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	806	0	1	04	01	H0885_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	807	0	1	04	01	H0885_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	808	0	1	04	01	H0885_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	809	0	1	04	01	H0885_809_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0885	810	0	1	04	01	H0885_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H0907	001	0	1	02	01	H0907_001_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontal Root Planing and Scaling - 1 per quadrant every 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H0907	003	0	1	02	01	H0907_003_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontal Root Planing and Scaling - 1 per quadrant every 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H0908	001	0	1	02	01	H0908_001_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0908	003	0	1	02	01	H0908_003_0	10	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0908	004	0	1	02	01	H0908_004_0	10	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0908	006	0	1	02	01	H0908_006_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0908	007	0	1	02	01	H0908_007_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0908	008	0	1	02	01	H0908_008_0	14	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0913	002	0	1	02	01	H0913_002_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0913	013	0	1	01	01	H0913_013_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H0913	015	0	1	02	01	H0913_015_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H0913	020	0	1	02	01	H0913_020_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H0913	021	0	1	02	01	H0913_021_0	9	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0913	022	0	1	02	01	H0913_022_0	10	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H0934	001	0	1	20	08	H0934_001_0	2																																																																																																																																																																																																																																																																																																		
H0934	002	0	1	20	08	H0934_002_0	2																																																																																																																																																																																																																																																																																																		
H0963	001	0	1	01	01	H0963_001_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H0976	001	0	1	01	01	H0976_001_0	10	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				1	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0976	002	0	1	01	01	H0976_002_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				1	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	001	0	1	01	01	H0978_001_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	002	0	1	01	01	H0978_002_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	010	0	1	01	01	H0978_010_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	011	0	1	01	01	H0978_011_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		235.00	5		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0978	802	0	1	01	01	H0978_802_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0978	803	0	1	01	01	H0978_803_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0978	804	0	1	01	01	H0978_804_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0978	805	0	1	01	01	H0978_805_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H0982	002	0	1	01	01	H0982_002_0	13	2				2				2				2		1	1	1		5000.00	3		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	007	0	1	01	01	H0982_007_0	12	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	008	0	1	01	01	H0982_008_0	10	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	009	0	1	01	01	H0982_009_0	10	2				2				2				2		1	1	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	010	0	1	01	01	H0982_010_0	10	2				2				2				2		1	1	1		4000.00	3		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	012	0	1	01	01	H0982_012_0	10	2				2				2				2		1	1	1		5000.00	3		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	013	0	1	01	01	H0982_013_0	10	2				2				2				2		1	1	1		5000.00	3		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	016	0	1	01	01	H0982_016_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	017	0	1	01	01	H0982_017_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	018	0	1	01	01	H0982_018_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	019	0	1	01	01	H0982_019_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	020	0	1	01	01	H0982_020_0	9	2				2				2				2		1	1	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	021	0	1	01	01	H0982_021_0	9	2				2				2				2		1	1	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	022	0	1	01	01	H0982_022_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	023	0	1	01	01	H0982_023_0	10	2				2				2				2		1	1	1		4000.00	3		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	024	0	1	01	01	H0982_024_0	9	2				2				2				2		1	1	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	025	0	1	01	01	H0982_025_0	10	2				2				2				2		1	1	1		4000.00	3		2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				2	2																2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2	2	2	1	6	see note below	2				2				1	2																2	2	1	6	see note below	2				2				1	2
H0982	026	0	1	01	01	H0982_026_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	027	0	1	01	01	H0982_027_0	9	2				2				2				2		1	1	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H0982	028	0	1	01	01	H0982_028_0	9	2				2				2				2		1	1	2					2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	030	0	1	01	01	H0982_030_0	9	2				2				2				2		1	1	2					2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	031	0	1	01	01	H0982_031_0	9	2				2				2				2		1	1	2					2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	032	0	1	01	01	H0982_032_0	9	2				2				2				2		1	1	2					2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H0982	033	0	1	01	01	H0982_033_0	9	2				2				2				2		1	1	2					2				2					2					2		2	2	1	6	see note below	2				2				2	2	2	2	1	6	see note below	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	6	see note below	2				2				1	2																																																																																																									
H1019	001	0	1	02	01	H1019_001_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	006	0	1	01	01	H1019_006_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	8	6	extractions for dentures unl/yr, extractions 6/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	023	0	1	01	01	H1019_023_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	043	0	1	02	01	H1019_043_0	4	2				2				1	15.00	15.00	15.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	057	0	1	02	01	H1019_057_0	5	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	065	0	1	01	01	H1019_065_0	3	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2						2					2		2	2	1	3		2				1	0.00	0.00	0.00	1	1																2	2	1	3		2				1	0.00	0.00	0.00	1	1																																																													2	2	1	3		2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	073	0	1	01	01	H1019_073_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	complete or partial dentures 1 set(s)/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	6	6	extractions for dentures unl/yr, extractions 6/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	094	0	1	01	01	H1019_094_0	3	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2						2					2		2	2	1	3		2				1	0.00	0.00	0.00	1	1																																																																																											2	2	1	3		2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	103	1	1	01	01	H1019_103_1	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	103	2	1	01	01	H1019_103_2	4	2				2				1	5.00	5.00	5.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																															2	2	1	6	part/comp dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	104	1	1	01	01	H1019_104_1	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	104	2	1	01	01	H1019_104_2	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	109	0	1	01	01	H1019_109_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1																2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	113	0	1	01	01	H1019_113_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	118	0	1	01	01	H1019_118_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	comp dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	3		2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	121	0	1	01	01	H1019_121_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	comp dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	123	0	1	01	01	H1019_123_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	comp dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	124	0	1	02	01	H1019_124_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	130	0	1	02	01	H1019_130_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	132	0	1	01	01	H1019_132_0	4	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	3	6	extractions for dentures unl/yr, extractions 3/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	134	0	1	01	01	H1019_134_0	3	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																															2	2	1	6	part/comp dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	135	0	1	02	01	H1019_135_0	4	2				2				1	25.00	25.00	25.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	136	0	1	01	01	H1019_136_0	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	138	0	1	01	01	H1019_138_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	139	0	1	01	01	H1019_139_0	3	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																															2	2	1	6	part/comp dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	144	0	1	01	01	H1019_144_0	6	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	1	3		2				1	0.00	0.00	0.00	1	2																																																													2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1019	146	0	1	01	01	H1019_146_0	6	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																															2	2	1	6	part/comp dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	147	1	1	01	01	H1019_147_1	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	147	2	1	01	01	H1019_147_2	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	148	0	1	01	01	H1019_148_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1019	149	0	1	01	01	H1019_149_0	4	2				2				1	15.00	15.00	15.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	150	0	1	01	01	H1019_150_0	6	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	151	1	1	01	01	H1019_151_1	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	5	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	151	2	1	01	01	H1019_151_2	4	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	5	6	extractions for dentures unl/yr, extractions 3/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	152	0	1	01	01	H1019_152_0	4	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	153	0	1	01	01	H1019_153_0	4	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	6	bitewing x-rays 1 set(s)/yr, pano film 1/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1																															2	2	1	6	part/comp dentures 1/5 yrs	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions for dentures unl/yr, extractions 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1019	154	0	1	01	01	H1019_154_0	5	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	2	2	2	3	3		2				1	0.00	0.00	0.00	1	2	2	2	1	1		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	4	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	2	6	complete or partial dentures 1 set(s)/5 yrs, reline 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	7	6	extractions for dentures unl/yr, extractions 5/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	1				2				1	0.00	0.00	0.00	1	1
H1032	193	0	1	01	01	H1032_193_0	9	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1032	194	0	1	01	01	H1032_194_0	9	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	195	0	1	01	01	H1032_195_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H1032	196	0	1	01	01	H1032_196_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	198	0	1	01	01	H1032_198_0	9	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1032	199	0	1	01	01	H1032_199_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	200	0	1	01	01	H1032_200_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1032	201	0	1	01	01	H1032_201_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	202	0	1	01	01	H1032_202_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	204	0	1	01	01	H1032_204_0	10	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1032	205	0	1	01	01	H1032_205_0	9	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	210	0	1	01	01	H1032_210_0	9	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1032	211	0	1	01	01	H1032_211_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	212	0	1	01	01	H1032_212_0	10	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1032	213	0	1	01	01	H1032_213_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	237	0	1	01	01	H1032_237_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	239	0	1	01	01	H1032_239_0	7	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	240	0	1	01	01	H1032_240_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	241	0	1	01	01	H1032_241_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	242	0	1	01	01	H1032_242_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	243	0	1	01	01	H1032_243_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	244	1	1	01	01	H1032_244_1	10	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	244	2	1	01	01	H1032_244_2	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	245	1	1	01	01	H1032_245_1	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1032	245	2	1	01	01	H1032_245_2	10	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1035	002	0	1	02	01	H1035_002_0	5	2				2				1	40.00	40.00	40.00	2		1	1																																																																																																																																																																																																																																																																																		
H1035	017	0	1	01	01	H1035_017_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	019	0	1	01	01	H1035_019_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	020	0	1	01	01	H1035_020_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	021	0	1	01	01	H1035_021_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	022	0	1	01	01	H1035_022_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H1035	025	0	1	01	01	H1035_025_0	8	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	026	0	1	01	01	H1035_026_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	033	0	1	01	01	H1035_033_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	034	0	1	01	01	H1035_034_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	040	0	1	01	01	H1035_040_0	5	2				2				1	50.00	50.00	50.00	2		1	1	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H1035	043	0	1	01	01	H1035_043_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1035	045	0	1	01	01	H1035_045_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	048	0	1	01	01	H1035_048_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	4	6	Fillings: Limited to two per year.Crowns: Limited to one per year when performed in conjunction with an eligible root canal procedure. Crown Supporting:  Limited to one per calendar year.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	Scaling and Root Planing: up to 4 quadrants total per 36 month period, limited to one procedure per quadrant.Full Mouth Debridement: limited to once per 36 month period.	2				1	0.00	0.00	0.00	2	2	2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H1035	052	0	1	01	01	H1035_052_0	9	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H1035	801	0	1	01	01	H1035_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1035	802	0	1	01	01	H1035_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1035	803	0	1	01	01	H1035_803_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1035	804	0	1	01	01	H1035_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1036	025	0	1	01	01	H1036_025_0	4	2				2				1	10.00	10.00	10.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	044	0	1	01	01	H1036_044_0	3	2				2				1	10.00	10.00	10.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	054	0	1	01	01	H1036_054_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		6000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	062	0	1	01	01	H1036_062_0	3	2				2				1	5.00	5.00	5.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	065	0	1	01	01	H1036_065_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		5000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	068	0	1	01	01	H1036_068_0	2	2				2				1	10.00	10.00	10.00	2		1	1	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	074	0	1	01	01	H1036_074_0	2	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	077	0	1	01	01	H1036_077_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		6000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	102	0	1	01	01	H1036_102_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	119	0	1	01	01	H1036_119_0	3	2				2				1	30.00	30.00	30.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	121	0	1	01	01	H1036_121_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	137	0	1	02	01	H1036_137_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1036	143	0	1	01	01	H1036_143_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	146	0	1	01	01	H1036_146_0	3	2				2				1	5.00	5.00	5.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	151	0	1	01	01	H1036_151_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1036	153	0	1	01	01	H1036_153_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	157	0	1	01	01	H1036_157_0	4	2				2				1	25.00	25.00	25.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	167	0	1	01	01	H1036_167_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	209	0	1	01	01	H1036_209_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	210	0	1	01	01	H1036_210_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	213	0	1	01	01	H1036_213_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	214	0	1	01	01	H1036_214_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	217	0	1	01	01	H1036_217_0	5	2				2				1	10.00	10.00	10.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	222	0	1	01	01	H1036_222_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	226	0	1	01	01	H1036_226_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	229	0	1	01	01	H1036_229_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H1036	230	0	1	01	01	H1036_230_0	4	2				2				1	5.00	5.00	5.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	233	0	1	02	01	H1036_233_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1036	234	0	1	01	01	H1036_234_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1036	235	0	1	01	01	H1036_235_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	236	0	1	01	01	H1036_236_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	265	1	1	01	01	H1036_265_1	3	2				2				1	10.00	10.00	10.00	2		1	1	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	265	2	1	01	01	H1036_265_2	4	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	1
H1036	266	0	1	01	01	H1036_266_0	2	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	269	0	1	01	01	H1036_269_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	270	0	1	01	01	H1036_270_0	2	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	271	0	1	01	01	H1036_271_0	3	2				2				1	35.00	35.00	35.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	278	0	1	01	01	H1036_278_0	2	2				2				1	35.00	35.00	35.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	1																2	2	2	1		2				1	25.00	25.00	25.00	1	1																																																																																											2	1				1	0	0	0	2				1	1
H1036	279	0	1	01	01	H1036_279_0	2	2				2				1	40.00	40.00	40.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	280	0	1	01	01	H1036_280_0	6	2				2				1	0.00	0.00	0.00	2		1	1	1		6000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	285	0	1	01	01	H1036_285_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	286	0	1	01	01	H1036_286_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	290	0	1	01	01	H1036_290_0	2	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	1																2	2	2	1		2				1	25.00	25.00	25.00	1	1																																																																																											2	1				1	0	0	0	2				1	1
H1036	292	0	1	01	01	H1036_292_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	1																2	2	2	1		2				1	25.00	25.00	25.00	1	1																																																																																											2	1				1	0	0	0	2				1	1
H1036	297	0	1	01	01	H1036_297_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	298	0	1	01	01	H1036_298_0	5	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	299	0	1	01	01	H1036_299_0	4	2				2				1	10.00	10.00	10.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	300	0	1	01	01	H1036_300_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	301	0	1	01	01	H1036_301_0	3	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	1																2	2	2	1		2				1	25.00	25.00	25.00	1	1																																																																																											2	1				2				1	0.00	0.00	0.00	1	1
H1036	302	0	1	01	01	H1036_302_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	304	0	1	01	01	H1036_304_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	305	0	1	01	01	H1036_305_0	3	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	1
H1036	306	0	1	01	01	H1036_306_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	307	0	1	01	01	H1036_307_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	308	0	1	01	01	H1036_308_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	310	0	1	01	01	H1036_310_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																																																																																																																									2	1				1	0	0	0	2				1	1
H1036	311	0	1	01	01	H1036_311_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	1																																																																																																																									2	1				1	0	0	0	2				1	1
H1036	312	0	1	01	01	H1036_312_0	6	2				2				1	10.00	10.00	10.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	313	0	1	01	01	H1036_313_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	314	0	1	01	01	H1036_314_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	315	0	1	01	01	H1036_315_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	1																2	2	2	1		2				1	25.00	25.00	25.00	1	1																																																																																											2	1				2				1	0.00	0.00	0.00	1	1
H1036	316	0	1	01	01	H1036_316_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	317	0	1	01	01	H1036_317_0	4	2				1	20	20	20	2				2		1	2	1		500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	318	0	1	02	01	H1036_318_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H1036	319	0	1	01	01	H1036_319_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H1036	320	0	1	01	01	H1036_320_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H1036	321	0	1	01	01	H1036_321_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	322	0	1	01	01	H1036_322_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	323	0	1	01	01	H1036_323_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H1036	324	0	1	01	01	H1036_324_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	325	0	1	01	01	H1036_325_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	326	0	1	01	01	H1036_326_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	327	0	1	01	01	H1036_327_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1036	328	0	1	01	01	H1036_328_0	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1036	329	0	1	01	01	H1036_329_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1036	330	0	1	01	01	H1036_330_0	4	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	331	0	1	01	01	H1036_331_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	332	0	1	01	01	H1036_332_0	3	2				2				1	20.00	20.00	20.00	2		1	1	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	333	0	1	01	01	H1036_333_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1036	334	0	1	01	01	H1036_334_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H1036	335	1	1	02	01	H1036_335_1	4	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1036	335	2	1	02	01	H1036_335_2	4	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1036	336	0	1	01	01	H1036_336_0	3	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	337	0	1	01	01	H1036_337_0	4	2				2				1	20.00	20.00	20.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	338	0	1	01	01	H1036_338_0	3	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1																2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	1				2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1036	339	0	1	01	01	H1036_339_0	3	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	340	0	1	01	01	H1036_340_0	3	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	341	0	1	01	01	H1036_341_0	3	2				1	20	20	20	2				2		1	1	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H1036	801	0	1	01	01	H1036_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	806	0	1	01	01	H1036_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	810	0	1	01	01	H1036_810_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	811	0	1	01	01	H1036_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	814	0	1	01	01	H1036_814_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	815	0	1	01	01	H1036_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	816	0	1	01	01	H1036_816_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	817	0	1	01	01	H1036_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	818	0	1	01	01	H1036_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	819	0	1	01	01	H1036_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	820	0	1	01	01	H1036_820_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	821	0	1	01	01	H1036_821_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	822	0	1	01	01	H1036_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	823	0	1	01	01	H1036_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	824	0	1	01	01	H1036_824_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	825	0	1	01	01	H1036_825_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	826	0	1	01	01	H1036_826_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	827	0	1	01	01	H1036_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	828	0	1	01	01	H1036_828_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	829	0	1	01	01	H1036_829_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	832	0	1	01	01	H1036_832_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1036	833	0	1	01	01	H1036_833_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1043	001	0	1	20	08	H1043_001_0	2																																																																																																																																																																																																																																																																																																		
H1043	002	0	1	20	08	H1043_002_0	2																																																																																																																																																																																																																																																																																																		
H1045	001	0	1	01	01	H1045_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	005	0	1	01	01	H1045_005_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	012	0	1	01	01	H1045_012_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	018	0	1	01	01	H1045_018_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	025	0	1	02	01	H1045_025_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	026	0	1	02	01	H1045_026_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	028	0	1	02	01	H1045_028_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	030	0	1	02	01	H1045_030_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	031	0	1	02	01	H1045_031_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	033	0	1	02	01	H1045_033_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	034	0	1	02	01	H1045_034_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	036	0	1	02	01	H1045_036_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	037	0	1	01	01	H1045_037_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	038	0	1	01	01	H1045_038_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	039	0	1	02	01	H1045_039_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1045	041	0	1	02	01	H1045_041_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	042	0	1	02	01	H1045_042_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	043	0	1	02	01	H1045_043_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	045	0	1	02	01	H1045_045_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	048	1	1	02	01	H1045_048_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	048	2	1	02	01	H1045_048_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	048	3	1	02	01	H1045_048_3	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	048	4	1	02	01	H1045_048_4	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	055	0	1	02	01	H1045_055_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	056	0	1	02	01	H1045_056_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	057	0	1	02	01	H1045_057_0	4	2				1	20	20	20	2				2		1	2	1		2250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	058	0	1	02	01	H1045_058_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	059	0	1	02	01	H1045_059_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1045	060	0	1	02	01	H1045_060_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	061	0	1	01	01	H1045_061_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	063	0	1	02	01	H1045_063_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1045	064	0	1	01	01	H1045_064_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H1045	065	0	1	02	01	H1045_065_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1045	067	0	1	02	01	H1045_067_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	069	0	1	02	01	H1045_069_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1045	801	0	1	01	01	H1045_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1045	802	0	1	01	01	H1045_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1045	803	0	1	01	01	H1045_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1045	804	0	2	01	01	H1045_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1099	001	0	1	02	01	H1099_001_0	7	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1099	006	0	1	01	01	H1099_006_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1099	009	0	1	01	01	H1099_009_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	014	0	1	01	01	H1099_014_0	8	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	016	0	1	01	01	H1099_016_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 to 36 months, depending on the procedure.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	023	0	1	01	01	H1099_023_0	6	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2						2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	024	0	1	01	01	H1099_024_0	6	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2						2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	025	0	1	02	01	H1099_025_0	6	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2						2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	026	0	1	01	01	H1099_026_0	7	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H1099	027	0	1	02	01	H1099_027_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 to 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1099	028	0	1	01	01	H1099_028_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Dental X-Rays are covered every 12 - 36 months, depending on the procedure.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2						2					2		2	2	1	6	Fillings are limited to coverage once every 2 years per surface per tooth. Crowns are limited to coverage once every 5 years per tooth.	2				2				2	2																2	2	1	6	Periodontics are covered every 6 to 36 months.	2				2				2	2																																																													2	2	1	6	Extractions are unlimited. Oroantral fistula closure is covered once every 60 months.	2				2				2	2																2	2	1	6	1 palliative treatment every 12 months. 1 consultation, every 6 months. 2 teledentistry every calendar year. Other services covered as needed.	2				2				2	2
H1109	005	0	1	01	01	H1109_005_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1109	801	0	1	01	01	H1109_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1109	802	0	1	01	01	H1109_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1112	006	0	1	02	01	H1112_006_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	033	0	1	02	01	H1112_033_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	034	0	1	02	01	H1112_034_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	038	0	1	02	01	H1112_038_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1112	039	0	1	02	01	H1112_039_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	042	0	1	02	01	H1112_042_0	9	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1112	043	0	1	02	01	H1112_043_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1112	044	0	1	02	01	H1112_044_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	046	0	1	02	01	H1112_046_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	047	0	1	02	01	H1112_047_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	048	0	1	02	01	H1112_048_0	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1112	049	0	1	02	01	H1112_049_0	9	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1119	001	0	1	01	01	H1119_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1170	002	0	1	01	01	H1170_002_0	6	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	008	0	1	01	01	H1170_008_0	6	2				2				1	0.00	0.00	0.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				1	0.00	0.00	0.00	1	1	2	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				1	0.00	0.00	0.00	1	1																															2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				1	0.00	0.00	0.00	1	1	2	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				1	0.00	0.00	0.00	1	1
H1170	009	0	1	01	01	H1170_009_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	011	0	1	01	01	H1170_011_0	6	2				2				1	0.00	0.00	0.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				1	0.00	0.00	0.00	1	1	2	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				1	0.00	0.00	0.00	1	1																															2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				1	0.00	0.00	0.00	1	1	2	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				1	0.00	0.00	0.00	1	1
H1170	012	0	1	01	01	H1170_012_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	013	0	1	02	01	H1170_013_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	014	0	1	01	01	H1170_014_0	5	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	015	0	1	01	01	H1170_015_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				1	0.00	0.00	0.00	1	1	2	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				1	0.00	0.00	0.00	1	1																															2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				1	0.00	0.00	0.00	1	1	2	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				1	0.00	0.00	0.00	1	1																2	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				1	0.00	0.00	0.00	1	1
H1170	016	0	1	01	01	H1170_016_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	017	0	1	01	01	H1170_017_0	5	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral - 1 series/2 years; Bitewings - 1 series/6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Assessment of salivary flow, Pulp vitality test, caries risk assessment: 1/2 years	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		4	2	1	6	crown or onlay per tooth: 1 per 5 years; filling procedures: 2 per year; crown or onlay procedures: 2 per year; 1 per tooth per 2 years: recement, crown repair, onlay repair necessitated by restorative material failure	2				3		18.00	464.00	1	1	4	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		22.00	625.00	1	1	4	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; scaling and root planing: 1 per quadrant/2 years; Full mouth debridement: 1/2 years	2				3		0.00	643.00	1	1	4	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; adjust denture: 2/year; Repair broken complete denture base: 1/year; Reline denture: 2/year	2				3		25.00	738.00	1	1																3													2	2	2	2	1	6	pontic: 1/tooth/5 years; retainer onlay or inlay: 1/tooth/5 years; retainer crown: 1/tooth/5 years; Re-cement or re-bond fixed partial denture: 1/2 years	2				3		44.00	528.00	1	1	4	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		0.00	490.00	1	1																4	2	1	6	Palliative treatment of dental pain: 1/day; External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		0.00	151.00	1	1
H1170	801	0	1	01	01	H1170_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1170	802	0	1	01	01	H1170_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1181	001	0		07	02	H1181_001_0	3																																																																																																																																																																																																																																																																																																		
H1188	001	0	1	20	08	H1188_001_0	1																																																																																																																																																																																																																																																																																																		
H1188	003	0	1	20	08	H1188_003_0	1																																																																																																																																																																																																																																																																																																		
H1189	002	0	1	01	01	H1189_002_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	003	0	1	01	01	H1189_003_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	004	0	1	01	01	H1189_004_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	005	0	1	01	01	H1189_005_0	7	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	007	0	1	01	01	H1189_007_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	008	0	1	01	01	H1189_008_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	009	0	1	01	01	H1189_009_0	5	2				2				1	40.00	40.00	40.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1189	010	0	1	01	01	H1189_010_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2	2	1				2				1	20.00	20.00	20.00	2	2																2	1				2				1	20.00	20.00	20.00	2	2
H1206	002	0	1	02	01	H1206_002_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	003	0	1	02	01	H1206_003_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	004	0	1	01	01	H1206_004_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	008	0	1	02	01	H1206_008_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1206	009	0	1	01	01	H1206_009_0	2	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1206	801	0	1	01	01	H1206_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1212	001	0	1	01	01	H1212_001_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1212	002	0	1	01	01	H1212_002_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1212	003	0	1	02	01	H1212_003_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1215	001	0	1	02	01	H1215_001_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1215	003	0	1	02	01	H1215_003_0	9	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1215	005	0	1	02	01	H1215_005_0	9	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1219	001	0	1	20	08	H1219_001_0	2																																																																																																																																																																																																																																																																																																		
H1219	002	0	1	20	08	H1219_002_0	2																																																																																																																																																																																																																																																																																																		
H1224	001	0	1	01	01	H1224_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2						2					2		2	2	1	6	1 crown per tooth every 7 years.	2				2				1	2	2	2	1	6	One Pulp Cap per tooth in a lifetime. One Pulpotomy/Pupal debridement per tooth in a lifetime.	2				2				2	2	2	2	1	6	1 Bone replacement graft & 1 Deep Cleaning per site/quad every 3 calendar years. 1 Gingival flap procedure or Guided tissue regeneration per quad every 3 years. 1 Moderate scaling every calendar year.	2				2				1	2	2	2	1	6	One partial denture (flexible base or resin base) per arch every 7 years.	2				2				1	2																															2	2	1	6	Bridge (retainer crown/pontic) 1 per tooth every 7 years	2				2				1	2	2	2	1	6	One Alveoloplasty, with or without extractions per site quad in a lifetime. One Bone replacement graft for ridge preservation per site in a lifetime.	2				2				1	2																2	2	1	6	One Consultation, other than requesting dentist every year. Five units of deep sedation or intravenous conscious sedation every calendar year. One Night Guard (Occlusal Guard) every 5 calendar years.	2				2				1	2
H1225	001	0	1	01	01	H1225_001_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H1225	003	0	1	01	01	H1225_003_0	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	Frequency of services: • Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime• Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				2				1	2	2	2	1	6	• Complete or immediate denture - 1 per 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				2				1	2																2	2	1	6	• Implants - one per 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1225	004	0	1	01	01	H1225_004_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime• Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				2				1	2	2	2	1	6	• Complete or immediate denture - 1 every 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				2				1	2																2	2	1	6	• Implants - one every 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1228	001	0	1	20	08	H1228_001_0	3																																																																																																																																																																																																																																																																																																		
H1228	002	0	1	20	08	H1228_002_0	3																																																																																																																																																																																																																																																																																																		
H1230	001	0	1	01	01	H1230_001_0	3	2				2				1	35.00	35.00	35.00	2		2	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2						2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	003	0	1	01	01	H1230_003_0	3	2				2				1	50.00	50.00	50.00	2		2	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2						2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	013	0	1	01	01	H1230_013_0	3	2				2				1	35.00	35.00	35.00	2		2	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2						2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	014	0	1	01	01	H1230_014_0	3	2				2				1	50.00	50.00	50.00	2		2	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	3		0	30	2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	2						2					2		4	2	1	2		1	30	30	30	2				2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																3													2	2	3													2	2	3													2	2																4	1				1	30	30	30	2				2	2
H1230	801	0	1	01	01	H1230_801_0	2	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H1230	803	0	1	01	01	H1230_803_0	2	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H1230	804	0	2	01	01	H1230_804_0	2	2				3		20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H1234	001	0	1	20	08	H1234_001_0	2																																																																																																																																																																																																																																																																																																		
H1234	002	0	1	20	08	H1234_002_0	2																																																																																																																																																																																																																																																																																																		
H1239	001	0	1	20	08	H1239_001_0	2																																																																																																																																																																																																																																																																																																		
H1239	002	0	1	20	08	H1239_002_0	2																																																																																																																																																																																																																																																																																																		
H1248	004	0	1	04	01	H1248_004_0	13	2				2				1	0.00	0.00	0.00	2		2	2	1	2	2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1248	007	0	1	04	01	H1248_007_0	12	2				2				1	0.00	0.00	0.00	2		2	2	1	2	2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1248	014	0	1	04	01	H1248_014_0	12	2				2				1	0.00	0.00	0.00	2		2	2	1	2	2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1248	801	0	1	04	01	H1248_801_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1248	802	0	1	04	01	H1248_802_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1248	803	0	1	04	01	H1248_803_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1278	003	0	1	04	01	H1278_003_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	005	0	1	04	01	H1278_005_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	010	0	1	04	01	H1278_010_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	013	0	1	04	01	H1278_013_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	014	0	1	04	01	H1278_014_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	015	0	1	04	01	H1278_015_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	016	0	1	04	01	H1278_016_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	018	0	1	04	01	H1278_018_0	3	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1278	020	0	1	04	01	H1278_020_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	021	0	1	04	01	H1278_021_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	024	0	1	04	01	H1278_024_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	025	0	1	04	01	H1278_025_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	026	0	1	04	01	H1278_026_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	027	0	1	04	01	H1278_027_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	028	0	1	04	01	H1278_028_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	029	0	1	04	01	H1278_029_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	030	0	1	04	01	H1278_030_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1278	031	0	1	04	01	H1278_031_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1278	032	0	1	04	01	H1278_032_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1280	001	0	1	01	01	H1280_001_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1285	001	0	1	01	01	H1285_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H1285	002	0	1	02	01	H1285_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H1290	001	0	1	01	01	H1290_001_0	7	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	002	0	1	01	01	H1290_002_0	7	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	003	0	1	01	01	H1290_003_0	7	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	005	0	1	01	01	H1290_005_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	013	0	1	01	01	H1290_013_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	014	0	1	01	01	H1290_014_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	015	0	1	01	01	H1290_015_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	018	0	1	01	01	H1290_018_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	019	0	1	01	01	H1290_019_0	7	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	020	0	1	01	01	H1290_020_0	7	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	021	0	1	01	01	H1290_021_0	7	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	022	0	1	01	01	H1290_022_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	023	0	1	01	01	H1290_023_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	024	0	1	01	01	H1290_024_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	025	0	1	01	01	H1290_025_0	8	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	027	0	1	01	01	H1290_027_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	029	0	1	01	01	H1290_029_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	031	0	1	01	01	H1290_031_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	032	0	1	01	01	H1290_032_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	033	0	1	01	01	H1290_033_0	8	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	034	0	1	01	01	H1290_034_0	8	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	035	0	1	01	01	H1290_035_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	036	1	1	01	01	H1290_036_1	7	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	036	2	1	01	01	H1290_036_2	7	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	037	1	1	01	01	H1290_037_1	8	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	037	2	1	01	01	H1290_037_2	11	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	037	3	1	01	01	H1290_037_3	8	2				2				2				2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	037	4	1	01	01	H1290_037_4	8	2				2				1	5.00	5.00	5.00	2		1	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	2		1500.00	3		2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	037	5	1	01	01	H1290_037_5	10	2				2				1	5.00	5.00	5.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	039	0	1	01	01	H1290_039_0	8	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	041	0	1	01	01	H1290_041_0	8	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	042	0	1	01	01	H1290_042_0	9	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	043	0	1	01	01	H1290_043_0	9	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	044	1	1	01	01	H1290_044_1	7	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	2		1500.00	3		2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	044	2	1	01	01	H1290_044_2	7	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	2		1500.00	3		2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	044	3	1	01	01	H1290_044_3	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	2		1500.00	3		2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	045	0	1	01	01	H1290_045_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	046	0	1	01	01	H1290_046_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	049	0	1	01	01	H1290_049_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	050	0	1	01	01	H1290_050_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	051	1	1	01	01	H1290_051_1	7	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	051	2	1	01	01	H1290_051_2	7	2				2				1	45.00	45.00	45.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	052	0	1	01	01	H1290_052_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	053	0	1	01	01	H1290_053_0	7	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	054	0	1	01	01	H1290_054_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	055	0	1	01	01	H1290_055_0	7	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	056	0	1	01	01	H1290_056_0	7	2				2				2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	057	0	1	01	01	H1290_057_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	058	0	1	01	01	H1290_058_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	059	0	1	01	01	H1290_059_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	060	0	1	01	01	H1290_060_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	061	0	1	01	01	H1290_061_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	062	0	1	01	01	H1290_062_0	7	2				2				2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	063	0	1	01	01	H1290_063_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	064	0	1	01	01	H1290_064_0	7	2				2				2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	065	0	1	01	01	H1290_065_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	066	0	1	01	01	H1290_066_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1290	067	0	1	01	01	H1290_067_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	068	0	1	01	01	H1290_068_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	069	0	1	01	01	H1290_069_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	070	0	1	01	01	H1290_070_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	071	0	1	01	01	H1290_071_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	072	0	1	01	01	H1290_072_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	073	0	1	01	01	H1290_073_0	7	2				2				1	5.00	5.00	5.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	074	0	1	01	01	H1290_074_0	7	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	077	0	1	01	01	H1290_077_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	078	0	1	01	01	H1290_078_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	079	0	1	01	01	H1290_079_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	080	0	1	01	01	H1290_080_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	081	0	1	01	01	H1290_081_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	082	0	1	01	01	H1290_082_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	083	0	1	01	01	H1290_083_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	084	0	1	01	01	H1290_084_0	9	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	085	0	1	01	01	H1290_085_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	086	0	1	01	01	H1290_086_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	087	0	1	01	01	H1290_087_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	088	0	1	01	01	H1290_088_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	089	0	1	01	01	H1290_089_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	090	0	1	01	01	H1290_090_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1290	091	0	1	01	01	H1290_091_0	7	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H1302	004	0	1	04	01	H1302_004_0	4	2				1	10	10	10	2				2		2	2	1	2	500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	2	2	1500.00	3		2					2		2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Implants not to exceed one per tooth every seven years.	2				1	300.00	300.00	300.00	1	2	2	2	1	6	Limited to one crown per year. Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	2				1	300.00	300.00	300.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1302	802	0	1	04	01	H1302_802_0	2	2				1	10	10	10	2				2		2	2																																																																																																																																																																																																																																																																																		
H1302	803	0	1	04	01	H1302_803_0	2	2				1	10	10	10	2				2		2	2																																																																																																																																																																																																																																																																																		
H1302	804	0	1	04	01	H1302_804_0	2	2				1	10	10	10	2				2		2	2																																																																																																																																																																																																																																																																																		
H1304	803	0	1	04	01	H1304_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1304	804	0	1	04	01	H1304_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1304	805	0	1	04	01	H1304_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1304	806	0	1	04	01	H1304_806_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1310	001	0	1	20	08	H1310_001_0	2																																																																																																																																																																																																																																																																																																		
H1310	003	0	1	20	08	H1310_003_0	2																																																																																																																																																																																																																																																																																																		
H1312	001	0	1	20	08	H1312_001_0	2																																																																																																																																																																																																																																																																																																		
H1312	002	0	1	20	08	H1312_002_0	2																																																																																																																																																																																																																																																																																																		
H1339	001	0	1	01	01	H1339_001_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2400.00	3		2					2		2	2	1	6	See notes for details	2				2				1	2	2	2	1	6	• Root canals and retreatment, apicoectomy, retrograde filling - once per tooth per lifetime• Pulpotomy, pulpal debridement - once per tooth per lifetime	2				2				1	2	2	2	1	6	• Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years• Full mouth debridement - once per 3 years• Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				2				1	2	2	2	1	6	• Complete or immediate denture - 1 per 5 years•  Adjustment of dentures - 2 per year after 6 months of initial placement• Repair dentures and replace/add teeth - once per tooth per year• Rebase or reline dentures - 1 per 3 years after 6 months of initial placement• Tissue conditioning	2				2				1	2																2	2	1	6	• Implants - one per 5 years per tooth• Re-cement implants - once every 2 years after 6 months of initial placement	2				2				1	2	2	2	1	6	• Partial denture - one every 5 years• Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				2				1	2	2	2	1	6	See notes for details	2				2				1	2																2	2	1	6	See notes for details	2				2				1	2
H1347	001	0	1	04	01	H1347_001_0	4	2				2				1	30.00	30.00	30.00	2		2	2	1	2	375.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																																																																																																																																			
H1347	002	0	1	04	01	H1347_002_0	4	2				2				1	30.00	30.00	30.00	2		2	2	1	2	375.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																																																																																																																																			
H1347	003	0	1	04	01	H1347_003_0	4	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1350	006	0	1	01	01	H1350_006_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1		500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	2		1000.00	3		2					2		2	2	1	6	Same tooth surface restoration is covered once in a two year period.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root canals not to exceed one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years. One set of dentures is covered every seven years.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Implants not to exceed one per tooth every seven years.	2				1	300.00	300.00	300.00	1	2	2	2	1	6	Limited to one crown per year. Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	2				1	300.00	300.00	300.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1350	032	0	1	01	01	H1350_032_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																		
H1350	033	0	1	01	01	H1350_033_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																		
H1350	034	0	1	01	01	H1350_034_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																		
H1350	035	0	1	01	01	H1350_035_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																		
H1350	036	0	1	01	01	H1350_036_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																		
H1350	037	0	1	01	01	H1350_037_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	3	6	Two oral exams per calendar year.One emergency oral exam per calendar year.	2								2	2	2	2	2	6	For x-rays, coverage is 1 bite wing every year: 1 full mouth x-ray every three years.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																																																																																																																																																																																		
H1350	803	0	1	01	01	H1350_803_0	2	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																		
H1350	804	0	1	01	01	H1350_804_0	2	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																		
H1350	805	0	1	01	01	H1350_805_0	2	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																		
H1350	806	0	1	02	01	H1350_806_0	2	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																		
H1350	807	0	1	02	01	H1350_807_0	2	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																		
H1357	001	0	1	20	08	H1357_001_0	2																																																																																																																																																																																																																																																																																																		
H1357	002	0	1	20	08	H1357_002_0	2																																																																																																																																																																																																																																																																																																		
H1360	001	0	1	02	01	H1360_001_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1360	002	0	1	02	01	H1360_002_0	4	2				1	20	20	20	2				2		1	1	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1360	003	0	1	02	01	H1360_003_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1365	001	0	1	04	01	H1365_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	1	1					2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H1365	005	0	1	04	01	H1365_005_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	1	1					2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H1365	802	0	1	04	01	H1365_802_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1365	803	0	1	04	01	H1365_803_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1372	001	0	1	01	01	H1372_001_0	6	2				1	20	20	20	2				2		1	2	1		700.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H1372	002	0	1	01	01	H1372_002_0	7	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H1372	003	0	1	01	01	H1372_003_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H1395	001	0	1	04	01	H1395_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1395	002	0	1	04	01	H1395_002_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H1395	003	0	1	04	01	H1395_003_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1395	004	0	1	04	01	H1395_004_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1396	001	0	1	01	01	H1396_001_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1416	009	0	1	02	01	H1416_009_0	8	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	026	0	1	02	01	H1416_026_0	8	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	033	0	1	02	01	H1416_033_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	034	0	1	02	01	H1416_034_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	035	0	1	02	01	H1416_035_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	042	0	1	02	01	H1416_042_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	043	0	1	02	01	H1416_043_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	044	0	1	02	01	H1416_044_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	055	0	1	02	01	H1416_055_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	058	0	1	02	01	H1416_058_0	7	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	060	0	1	02	01	H1416_060_0	7	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	061	0	1	02	01	H1416_061_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	064	0	1	02	01	H1416_064_0	7	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	065	0	1	02	01	H1416_065_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	068	0	1	02	01	H1416_068_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	071	0	1	02	01	H1416_071_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	072	0	1	02	01	H1416_072_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	077	0	1	02	01	H1416_077_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	079	0	1	02	01	H1416_079_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1416	081	0	1	02	01	H1416_081_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	082	0	1	02	01	H1416_082_0	8	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1416	083	0	1	02	01	H1416_083_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1423	001	0	1	02	01	H1423_001_0	4	2				2				3		0.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	002	0	1	02	01	H1423_002_0	4	2				2				3		0.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	004	0	1	02	01	H1423_004_0	4	2				2				3		0.00	30.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1423	005	0	1	01	01	H1423_005_0	7	2				2				3		0.00	30.00	2		1	2																																																																																																																																																																																																																																																																																		
H1423	007	0	1	01	01	H1423_007_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	008	0	1	01	01	H1423_008_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1423	009	0	1	02	01	H1423_009_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1468	007	0	1	01	01	H1468_007_0	3	2				2				1	25.00	25.00	25.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1468	013	0	1	01	01	H1468_013_0	3	2				2				1	10.00	10.00	10.00	2		1	1	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1468	017	0	1	01	01	H1468_017_0	5	2				2				1	15.00	15.00	15.00	2		1	1	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1468	021	0	1	01	01	H1468_021_0	2	2				2				1	35.00	35.00	35.00	2		1	1	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H1468	802	0	1	01	01	H1468_802_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1468	803	0	1	01	01	H1468_803_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1468	805	0	1	01	01	H1468_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1468	806	0	1	01	01	H1468_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1486	001	0	1	01	01	H1486_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1500	001	0	1	20	08	H1500_001_0	2																																																																																																																																																																																																																																																																																																		
H1500	002	0	1	20	08	H1500_002_0	2																																																																																																																																																																																																																																																																																																		
H1518	001	0	1	20	08	H1518_001_0	2																																																																																																																																																																																																																																																																																																		
H1518	002	0	1	20	08	H1518_002_0	2																																																																																																																																																																																																																																																																																																		
H1526	001	0	1	02	01	H1526_001_0	5	2				2				1	20.00	20.00	20.00	2		2	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	002	0	1	02	01	H1526_002_0	5	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	003	0	1	02	01	H1526_003_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	Limited to 1 upper, 1 lower full or partial denture per 5 years	1	50	50	50	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	004	0	1	02	01	H1526_004_0	4	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	008	0	1	02	01	H1526_008_0	4	2				2				1	5.00	5.00	5.00	2		2	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1526	009	0	1	02	01	H1526_009_0	4	2				2				1	5.00	5.00	5.00	2		2	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower denture per 5 years	1	50	50	50	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H1533	001	0	1	20	08	H1533_001_0	2																																																																																																																																																																																																																																																																																																		
H1533	002	0	1	20	08	H1533_002_0	2																																																																																																																																																																																																																																																																																																		
H1537	801	0	1	04	01	H1537_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	802	0	1	04	01	H1537_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	803	0	1	04	01	H1537_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	804	0	2	04	01	H1537_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	805	0	2	04	01	H1537_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	806	0	2	04	01	H1537_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	807	0	1	04	01	H1537_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	808	0	1	04	01	H1537_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	809	0	1	04	01	H1537_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	816	0	1	04	01	H1537_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	817	0	1	04	01	H1537_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	823	0	1	04	01	H1537_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	824	0	1	04	01	H1537_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	825	0	1	04	01	H1537_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	826	0	1	04	01	H1537_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	827	0	2	04	01	H1537_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	828	0	2	04	01	H1537_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	829	0	2	04	01	H1537_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	830	0	1	04	01	H1537_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	831	0	1	04	01	H1537_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	832	0	1	04	01	H1537_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	833	0	1	04	01	H1537_833_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	834	0	1	04	01	H1537_834_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	835	0	2	04	01	H1537_835_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	836	0	1	04	01	H1537_836_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	837	0	1	04	01	H1537_837_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	838	0	1	04	01	H1537_838_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	839	0	1	04	01	H1537_839_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	840	0	1	04	01	H1537_840_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	841	0	1	04	01	H1537_841_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	842	0	1	04	01	H1537_842_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	843	0	1	04	01	H1537_843_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	844	0	1	04	01	H1537_844_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	845	0	1	04	01	H1537_845_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	846	0	1	04	01	H1537_846_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	847	0	1	04	01	H1537_847_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	848	0	1	04	01	H1537_848_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	849	0	1	04	01	H1537_849_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	850	0	1	04	01	H1537_850_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	851	0	1	04	01	H1537_851_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	852	0	1	04	01	H1537_852_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	853	0	1	04	01	H1537_853_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	854	0	1	04	01	H1537_854_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	855	0	1	04	01	H1537_855_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	856	0	1	04	01	H1537_856_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	857	0	1	04	01	H1537_857_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	858	0	1	04	01	H1537_858_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	859	0	1	04	01	H1537_859_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	860	0	1	04	01	H1537_860_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	861	0	1	04	01	H1537_861_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	862	0	1	04	01	H1537_862_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	863	0	1	04	01	H1537_863_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	864	0	1	04	01	H1537_864_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	865	0	1	04	01	H1537_865_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	866	0	1	04	01	H1537_866_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	867	0	1	04	01	H1537_867_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	868	0	1	04	01	H1537_868_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1537	869	0	1	04	01	H1537_869_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1544	001	0	1	20	08	H1544_001_0	2																																																																																																																																																																																																																																																																																																		
H1544	002	0	1	20	08	H1544_002_0	2																																																																																																																																																																																																																																																																																																		
H1587	001	0	1	01	01	H1587_001_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1587	003	0	1	02	01	H1587_003_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1607	012	0	1	04	01	H1607_012_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1800.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1607	015	0	1	04	01	H1607_015_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H1607	809	0	1	04	01	H1607_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	811	0	1	04	01	H1607_811_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	812	0	1	04	01	H1607_812_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	813	0	1	04	01	H1607_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	815	0	1	04	01	H1607_815_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	816	0	1	04	01	H1607_816_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	817	0	2	04	01	H1607_817_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	819	0	2	04	01	H1607_819_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1607	820	0	2	04	01	H1607_820_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1608	001	0	1	04	01	H1608_001_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	012	0	1	04	01	H1608_012_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	013	0	1	04	01	H1608_013_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	016	0	1	04	01	H1608_016_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	017	0	1	04	01	H1608_017_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	018	0	1	04	01	H1608_018_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	021	0	1	04	01	H1608_021_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	024	0	1	04	01	H1608_024_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	027	0	1	04	01	H1608_027_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	028	0	1	04	01	H1608_028_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	029	0	1	04	01	H1608_029_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	031	0	1	04	01	H1608_031_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	037	0	1	04	01	H1608_037_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	038	0	1	04	01	H1608_038_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	040	0	1	04	01	H1608_040_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	050	0	1	04	01	H1608_050_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	051	0	1	04	01	H1608_051_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	052	0	1	04	01	H1608_052_0	2	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	054	0	1	04	01	H1608_054_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	061	0	1	04	01	H1608_061_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	062	0	1	04	01	H1608_062_0	2	2				1	20	20	20	2				2		1	2	1	2	1275.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	067	0	1	04	01	H1608_067_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	070	0	1	04	01	H1608_070_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	072	0	1	04	01	H1608_072_0	2	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	074	0	1	04	01	H1608_074_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	076	0	1	04	01	H1608_076_0	2	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	077	0	1	04	01	H1608_077_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	079	0	1	04	01	H1608_079_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	081	0	1	04	01	H1608_081_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	085	0	1	04	01	H1608_085_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	105	0	1	04	01	H1608_105_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	109	0	1	04	01	H1608_109_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1608	117	0	1	04	01	H1608_117_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	118	0	1	04	01	H1608_118_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	119	0	1	04	01	H1608_119_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	120	0	1	04	01	H1608_120_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1608	121	0	1	04	01	H1608_121_0	2	2				1	20	20	20	2				2		1	2	1	2	1900.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1608	801	0	1	04	01	H1608_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1609	001	0	1	02	01	H1609_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		900.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1609	017	0	1	01	01	H1609_017_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	018	0	1	01	01	H1609_018_0	2	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	019	0	1	01	01	H1609_019_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	020	0	1	01	01	H1609_020_0	2	2				2				1	5.00	5.00	5.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	021	0	1	01	01	H1609_021_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	022	0	1	01	01	H1609_022_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	025	0	1	01	01	H1609_025_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	027	0	1	01	01	H1609_027_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	028	0	1	02	01	H1609_028_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	041	0	1	01	01	H1609_041_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	043	0	1	01	01	H1609_043_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	044	0	1	01	01	H1609_044_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	045	0	1	01	01	H1609_045_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	046	0	1	01	01	H1609_046_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	047	0	1	01	01	H1609_047_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	048	0	1	01	01	H1609_048_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	049	0	1	01	01	H1609_049_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	055	0	1	01	01	H1609_055_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	056	0	1	01	01	H1609_056_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	058	0	1	02	01	H1609_058_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1609	059	0	1	01	01	H1609_059_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	061	0	1	01	01	H1609_061_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	062	0	1	01	01	H1609_062_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	063	0	1	01	01	H1609_063_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	064	0	1	01	01	H1609_064_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	068	0	1	02	01	H1609_068_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1100.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1609	069	0	1	02	01	H1609_069_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1609	073	0	1	01	01	H1609_073_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	074	0	1	01	01	H1609_074_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	075	0	1	01	01	H1609_075_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	076	0	1	01	01	H1609_076_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	077	0	1	01	01	H1609_077_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	078	0	1	01	01	H1609_078_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	079	0	1	01	01	H1609_079_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	080	0	1	01	01	H1609_080_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	081	0	1	01	01	H1609_081_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	082	0	1	01	01	H1609_082_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	083	0	1	01	01	H1609_083_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	084	0	1	01	01	H1609_084_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	085	0	1	01	01	H1609_085_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	086	0	1	01	01	H1609_086_0	2	2				2				1	10.00	10.00	10.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	087	0	1	01	01	H1609_087_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	088	0	1	01	01	H1609_088_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	089	0	1	01	01	H1609_089_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	090	0	1	01	01	H1609_090_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	092	0	1	01	01	H1609_092_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	093	0	1	01	01	H1609_093_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	094	0	1	01	01	H1609_094_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H1609	801	0	1	01	01	H1609_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1609	807	0	1	01	01	H1609_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1610	001	0	1	01	01	H1610_001_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1611	001	0	1	01	01	H1611_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1619	001	0	1	04	01	H1619_001_0	20	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H1619	002	0	1	04	01	H1619_002_0	19	2				2				1	20.00	20.00	20.00	2		2	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	3	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H1619	003	0	1	04	01	H1619_003_0	20	2				2				1	15.00	15.00	15.00	2		2	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H1622	001	0	1	20	08	H1622_001_0	2																																																																																																																																																																																																																																																																																																		
H1622	003	0	1	20	08	H1622_003_0	2																																																																																																																																																																																																																																																																																																		
H1644	001	0	1	01	01	H1644_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1651	001	0	1	18	06	H1651_001_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	002	0	1	18	06	H1651_002_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	003	0	1	18	06	H1651_003_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	004	0	1	18	06	H1651_004_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	005	0	1	18	06	H1651_005_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	008	0	1	18	06	H1651_008_0	2	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	009	0	1	18	06	H1651_009_0	2	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	013	0	1	18	06	H1651_013_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1651	015	0	1	18	06	H1651_015_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H1659	002	0	1	04	01	H1659_002_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1664	001	0	1	02	01	H1664_001_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1664	005	0	1	02	01	H1664_005_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1664	006	0	1	02	01	H1664_006_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1664	012	0	1	02	01	H1664_012_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1666	003	0	1	04	01	H1666_003_0	6	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1666	006	0	1	04	01	H1666_006_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1666	008	0	1	04	01	H1666_008_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1666	012	0	1	04	01	H1666_012_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1666	014	0	1	04	01	H1666_014_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1666	016	0	1	04	01	H1666_016_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H1666	019	0	1	04	01	H1666_019_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1666	020	0	1	04	01	H1666_020_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H1666	021	0	1	04	01	H1666_021_0	6	2				2				1	0.00	0.00	0.00	2		2	2																																																																																																																																																																																																																																																																																		
H1666	022	0	1	04	01	H1666_022_0	5	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H1666	023	0	1	04	01	H1666_023_0	7	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1666	024	0	1	04	01	H1666_024_0	5	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H1666	801	0	1	04	01	H1666_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1666	803	0	1	04	01	H1666_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1666	805	0	1	04	01	H1666_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1666	807	0	1	04	01	H1666_807_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1666	808	0	1	04	01	H1666_808_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1671	001	0	1	01	01	H1671_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																1	2		2000.00	3		2					2		2	1				2				2				1	2																																																																												2	1				2				2				1	2																																													
H1692	002	0	1	01	01	H1692_002_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1692	003	0	1	01	01	H1692_003_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H1692	005	0	1	01	01	H1692_005_0	2	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1692	006	0	1	01	01	H1692_006_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H1692	007	0	1	01	01	H1692_007_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H1692	801	0	1	01	01	H1692_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1693	002	0	1	20	08	H1693_002_0	2																																																																																																																																																																																																																																																																																																		
H1693	003	0	1	20	08	H1693_003_0	2																																																																																																																																																																																																																																																																																																		
H1714	001	0	1	20	08	H1714_001_0	3																																																																																																																																																																																																																																																																																																		
H1714	002	0	1	20	08	H1714_002_0	3																																																																																																																																																																																																																																																																																																		
H1722	002	0	1	01	01	H1722_002_0	6	2				2				2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	1				2				2				1	2	1	1					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H1742	001	0	1	20	08	H1742_001_0	2																																																																																																																																																																																																																																																																																																		
H1742	002	0	1	20	08	H1742_002_0	2																																																																																																																																																																																																																																																																																																		
H1787	001	0	1	01	01	H1787_001_0	5	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays limit to once every 5 years. Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex are covered once in a 5 year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	2				2				2	2																2	2	1	6	Implants are covered once per tooth per five-year period.	2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every 2 years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2
H1787	002	0	1	01	01	H1787_002_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Limit of once every 5 years. Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex are payable once in a five year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	2	1	6	Implants are covered once per tooth per five-year period.	2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every 2 years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1799	003	1	1	01	01	H1799_003_1	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H1799	003	2	1	01	01	H1799_003_2	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		500.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H1799	003	3	1	01	01	H1799_003_3	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H1799	004	0	1	01	01	H1799_004_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H1799	005	0	1	01	01	H1799_005_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H1822	001	0	1	01	01	H1822_001_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	002	0	1	01	01	H1822_002_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	005	0	1	02	01	H1822_005_0	6	2				2				2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	006	0	1	01	01	H1822_006_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	007	0	1	01	01	H1822_007_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		250.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1822	008	0	1	02	01	H1822_008_0	6	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2500.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1822	801	0	1	01	01	H1822_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1822	802	0	1	01	01	H1822_802_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1822	803	0	1	01	01	H1822_803_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1822	804	0	1	01	01	H1822_804_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1846	005	0	1	04	01	H1846_005_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H1846	006	0	1	04	01	H1846_006_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H1846	007	0	1	04	01	H1846_007_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H1846	801	0	1	04	01	H1846_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1846	803	0	1	04	01	H1846_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1846	804	0	1	04	01	H1846_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1846	805	0	1	04	01	H1846_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1862	003	0	1	02	01	H1862_003_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1862	004	0	1	02	01	H1862_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1862	005	0	1	02	01	H1862_005_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1862	006	0	1	02	01	H1862_006_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1889	002	1	1	04	01	H1889_002_1	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	002	2	1	04	01	H1889_002_2	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	005	0	1	04	01	H1889_005_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	007	0	1	04	01	H1889_007_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	008	0	1	04	01	H1889_008_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	009	0	1	04	01	H1889_009_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	010	0	1	04	01	H1889_010_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	011	0	1	04	01	H1889_011_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	012	0	1	04	01	H1889_012_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	013	0	1	04	01	H1889_013_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1889	014	0	1	04	01	H1889_014_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1889	015	0	1	04	01	H1889_015_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1889	016	0	1	04	01	H1889_016_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1889	017	0	1	04	01	H1889_017_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1889	018	0	1	04	01	H1889_018_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1889	019	0	1	04	01	H1889_019_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1889	020	0	1	04	01	H1889_020_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1889	022	0	1	04	01	H1889_022_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1889	025	0	1	04	01	H1889_025_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1889	026	0	1	04	01	H1889_026_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	028	0	1	04	01	H1889_028_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1889	030	0	1	04	01	H1889_030_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	031	0	1	04	01	H1889_031_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	032	0	1	04	01	H1889_032_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1889	034	0	1	04	01	H1889_034_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1889	035	0	1	04	01	H1889_035_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1894	002	0	1	01	01	H1894_002_0	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontal Root Planing and Scaling - 1 per quadrant every 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1894	011	0	1	01	01	H1894_011_0	7	2				1	20	20	20	2				2		1	2	1		2400.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontal Root Planing and Scaling - 1 per quadrant every 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1904	001	0	1	20	08	H1904_001_0	2																																																																																																																																																																																																																																																																																																		
H1904	002	0	1	20	08	H1904_002_0	3																																																																																																																																																																																																																																																																																																		
H1914	001	0	1	04	01	H1914_001_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1914	002	0	1	04	01	H1914_002_0	8	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1914	007	0	1	04	01	H1914_007_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1914	008	0	1	04	01	H1914_008_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H1914	009	0	1	04	01	H1914_009_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1914	010	0	1	04	01	H1914_010_0	8	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1914	011	0	1	04	01	H1914_011_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H1917	001	0	1	20	08	H1917_001_0	2																																																																																																																																																																																																																																																																																																		
H1917	002	0	1	20	08	H1917_002_0	2																																																																																																																																																																																																																																																																																																		
H1947	001	0	1	01	01	H1947_001_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1947	003	0	1	01	01	H1947_003_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1947	004	0	1	01	01	H1947_004_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H1951	013	0	1	01	01	H1951_013_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	024	0	1	01	01	H1951_024_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	028	0	1	01	01	H1951_028_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	032	0	1	01	01	H1951_032_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	038	0	1	01	01	H1951_038_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	039	0	1	01	01	H1951_039_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	041	0	1	01	01	H1951_041_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	044	0	1	01	01	H1951_044_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	047	1	1	01	01	H1951_047_1	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	047	2	1	01	01	H1951_047_2	3	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	048	1	1	01	01	H1951_048_1	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	048	2	1	01	01	H1951_048_2	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	049	1	1	01	01	H1951_049_1	2	2				2				1	25.00	25.00	25.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	049	2	1	01	01	H1951_049_2	3	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	049	3	1	01	01	H1951_049_3	2	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	051	0	1	01	01	H1951_051_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	052	0	1	01	01	H1951_052_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H1951	053	0	1	01	01	H1951_053_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	056	0	1	01	01	H1951_056_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H1951	057	0	1	01	01	H1951_057_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	058	0	1	01	01	H1951_058_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	059	0	1	01	01	H1951_059_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	060	0	1	01	01	H1951_060_0	1	2				2				1	40.00	40.00	40.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H1951	061	0	1	01	01	H1951_061_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H1951	801	0	1	01	01	H1951_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1951	804	0	1	01	01	H1951_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1951	807	0	1	01	01	H1951_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1951	808	0	1	01	01	H1951_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H1961	003	0	1	02	01	H1961_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	014	1	1	02	01	H1961_014_1	4	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	014	2	1	02	01	H1961_014_2	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	014	3	1	02	01	H1961_014_3	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	014	4	1	02	01	H1961_014_4	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	017	0	1	02	01	H1961_017_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	019	0	1	02	01	H1961_019_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1961	020	0	1	02	01	H1961_020_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1961	022	0	1	02	01	H1961_022_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	023	0	1	02	01	H1961_023_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1961	024	0	1	02	01	H1961_024_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H1961	025	0	1	02	01	H1961_025_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H1961	026	0	1	02	01	H1961_026_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H1961	801	0	1	02	01	H1961_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1961	802	0	1	02	01	H1961_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1961	803	0	1	01	01	H1961_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1961	804	0	1	01	01	H1961_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H1969	805	0	1	01	01	H1969_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1980	001	0	1	20	08	H1980_001_0	2																																																																																																																																																																																																																																																																																																		
H1980	002	0	1	20	08	H1980_002_0	2																																																																																																																																																																																																																																																																																																		
H1993	001	0	1	01	01	H1993_001_0	5	2				1	20	20	20	2				2		1	1	1		250.00	5		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	007	0	1	01	01	H1993_007_0	6	2				1	20	20	20	2				2		1	1	1		350.00	5		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1					2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H1993	008	0	1	01	01	H1993_008_0	5	2				1	20	20	20	2				2		1	1	1		550.00	5		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	011	0	1	01	01	H1993_011_0	5	2				1	20	20	20	2				2		1	1	1		300.00	5		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	012	0	1	01	01	H1993_012_0	5	2				2				2				2		1	1	1		875.00	5		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	3		2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1993	013	0	1	01	01	H1993_013_0	5	2				1	20	20	20	2				2		1	1	1		350.00	5		2				2					2					2		2	2	2	3		2				2				2	2	2	2	8	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1993	015	0	1	01	01	H1993_015_0	5	2				1	20	20	20	2				2		1	1	1		350.00	5		2				2					2					2		2	2	2	3		2				2				1	2	2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	4		2				2				1	2	2	2	1	3		2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H1994	001	0	1	01	01	H1994_001_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1					2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	012	0	1	01	01	H1994_012_0	6	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1					2					2		2	1				3		0	20	2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	015	0	1	01	01	H1994_015_0	4	2				1	30	30	30	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	016	0	1	01	01	H1994_016_0	1	2				2				1	50.00	50.00	50.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				2	2	1	1					2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	017	0	1	01	01	H1994_017_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																2	2	1	4		2				2				1	2	1	1					2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	021	0	1	01	01	H1994_021_0	5	2				2				2				2		1	2	1		1250.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				3		20	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1994	022	0	1	01	01	H1994_022_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				2	2																2	2	1	4		2				2				1	2	1	1					2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2
H1994	027	0	1	01	01	H1994_027_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	029	0	1	01	01	H1994_029_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	030	0	1	01	01	H1994_030_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	031	0	1	01	01	H1994_031_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1994	033	0	1	01	01	H1994_033_0	3	2				2				1	70.00	70.00	70.00	2		2	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H1994	034	0	1	01	01	H1994_034_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	035	0	1	01	01	H1994_035_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	040	0	1	01	01	H1994_040_0	4	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H1994	044	0	1	01	01	H1994_044_0	6	2				2				2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H1994	801	0	1	01	01	H1994_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1994	802	0	1	01	01	H1994_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1994	803	0	1	01	01	H1994_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H1997	013	0	1	01	01	H1997_013_0	5	2				2				1	55.00	55.00	55.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H2001	010	0	1	04	01	H2001_010_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	017	0	1	04	01	H2001_017_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	019	0	1	04	01	H2001_019_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	021	0	1	04	01	H2001_021_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	023	0	1	04	01	H2001_023_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	028	0	1	04	01	H2001_028_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	030	0	1	04	01	H2001_030_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	031	0	1	04	01	H2001_031_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	032	0	1	04	01	H2001_032_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	034	0	1	04	01	H2001_034_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	035	0	1	04	01	H2001_035_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	036	0	1	04	01	H2001_036_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	037	0	1	04	01	H2001_037_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	038	0	1	04	01	H2001_038_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	039	0	1	04	01	H2001_039_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	040	0	1	04	01	H2001_040_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	041	0	1	04	01	H2001_041_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	042	0	1	04	01	H2001_042_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	043	0	1	04	01	H2001_043_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	044	0	1	04	01	H2001_044_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	045	0	1	04	01	H2001_045_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	046	0	1	04	01	H2001_046_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	047	0	1	04	01	H2001_047_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	048	0	1	04	01	H2001_048_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	049	0	1	04	01	H2001_049_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	050	0	1	04	01	H2001_050_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	051	0	1	04	01	H2001_051_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	052	0	1	04	01	H2001_052_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	053	0	1	04	01	H2001_053_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	054	0	1	04	01	H2001_054_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	055	0	1	04	01	H2001_055_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	056	0	1	04	01	H2001_056_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	058	0	1	04	01	H2001_058_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	059	0	1	04	01	H2001_059_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	060	0	1	04	01	H2001_060_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	061	0	1	04	01	H2001_061_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	062	0	1	04	01	H2001_062_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	063	1	1	04	01	H2001_063_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	063	2	1	04	01	H2001_063_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	065	0	1	04	01	H2001_065_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	066	0	1	04	01	H2001_066_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	068	1	1	04	01	H2001_068_1	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	068	2	1	04	01	H2001_068_2	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	069	1	1	04	01	H2001_069_1	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	069	2	1	04	01	H2001_069_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	070	0	1	04	01	H2001_070_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	075	0	1	04	01	H2001_075_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	076	0	1	04	01	H2001_076_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	077	0	1	04	01	H2001_077_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	078	0	1	04	01	H2001_078_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	079	0	1	04	01	H2001_079_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	080	0	1	04	01	H2001_080_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	081	0	1	04	01	H2001_081_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	082	0	1	04	01	H2001_082_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	083	1	1	04	01	H2001_083_1	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	083	2	1	04	01	H2001_083_2	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	084	0	1	04	01	H2001_084_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	085	0	1	04	01	H2001_085_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2001	087	0	1	04	01	H2001_087_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	090	0	1	04	01	H2001_090_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	094	0	1	04	01	H2001_094_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	095	0	1	04	01	H2001_095_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	096	0	1	04	01	H2001_096_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	097	0	1	04	01	H2001_097_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	098	0	1	04	01	H2001_098_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	099	0	1	04	01	H2001_099_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	102	0	1	04	01	H2001_102_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	103	0	1	04	01	H2001_103_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	104	0	1	04	01	H2001_104_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	108	0	1	04	01	H2001_108_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	109	0	1	04	01	H2001_109_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	110	0	1	04	01	H2001_110_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	115	0	1	04	01	H2001_115_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	116	0	1	04	01	H2001_116_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	117	0	1	04	01	H2001_117_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	118	0	1	04	01	H2001_118_0	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	119	0	1	04	01	H2001_119_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	120	0	1	04	01	H2001_120_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	123	0	1	04	01	H2001_123_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	124	0	1	04	01	H2001_124_0	3	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	125	0	1	04	01	H2001_125_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	126	0	1	04	01	H2001_126_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	127	0	1	04	01	H2001_127_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	128	0	1	04	01	H2001_128_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	131	0	1	04	01	H2001_131_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	132	0	1	04	01	H2001_132_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	133	0	1	04	01	H2001_133_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	134	0	1	04	01	H2001_134_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	135	0	1	04	01	H2001_135_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	136	0	1	04	01	H2001_136_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	137	0	1	04	01	H2001_137_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2001	138	0	1	04	01	H2001_138_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	139	0	1	04	01	H2001_139_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2001	816	0	1	04	01	H2001_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	817	0	1	04	01	H2001_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	818	0	1	04	01	H2001_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	819	0	2	04	01	H2001_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	820	0	2	04	01	H2001_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	821	0	2	04	01	H2001_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	822	0	1	04	01	H2001_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	823	0	1	04	01	H2001_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	824	0	1	04	01	H2001_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	825	0	1	04	01	H2001_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	826	0	1	04	01	H2001_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	827	0	1	04	01	H2001_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	828	0	1	04	01	H2001_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	829	0	1	04	01	H2001_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	830	0	1	04	01	H2001_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	831	0	1	04	01	H2001_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	832	0	2	04	01	H2001_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	833	0	2	04	01	H2001_833_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	834	0	2	04	01	H2001_834_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	835	0	1	04	01	H2001_835_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	836	0	1	04	01	H2001_836_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	837	0	1	04	01	H2001_837_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	838	0	1	04	01	H2001_838_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	839	0	2	04	01	H2001_839_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	840	0	1	04	01	H2001_840_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	841	0	1	04	01	H2001_841_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	842	0	1	04	01	H2001_842_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	843	0	1	04	01	H2001_843_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	844	0	1	04	01	H2001_844_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	845	0	1	04	01	H2001_845_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	846	0	1	04	01	H2001_846_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	847	0	1	04	01	H2001_847_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	848	0	1	04	01	H2001_848_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	849	0	1	04	01	H2001_849_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	850	0	1	04	01	H2001_850_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	851	0	1	04	01	H2001_851_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	852	0	1	04	01	H2001_852_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	853	0	1	04	01	H2001_853_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	854	0	1	04	01	H2001_854_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	855	0	1	04	01	H2001_855_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	856	0	1	04	01	H2001_856_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	857	0	1	04	01	H2001_857_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	858	0	1	04	01	H2001_858_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	859	0	1	04	01	H2001_859_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	860	0	1	04	01	H2001_860_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	861	0	1	04	01	H2001_861_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	862	0	1	04	01	H2001_862_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	863	0	1	04	01	H2001_863_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	864	0	1	04	01	H2001_864_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	865	0	1	04	01	H2001_865_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	866	0	1	04	01	H2001_866_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	867	0	1	04	01	H2001_867_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	868	0	1	04	01	H2001_868_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	869	0	1	04	01	H2001_869_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	870	0	1	04	01	H2001_870_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	871	0	1	04	01	H2001_871_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	872	0	1	04	01	H2001_872_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	873	0	1	04	01	H2001_873_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	874	0	1	04	01	H2001_874_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	875	0	1	04	01	H2001_875_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	876	0	1	04	01	H2001_876_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	877	0	1	04	01	H2001_877_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	878	0	1	04	01	H2001_878_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	879	0	1	04	01	H2001_879_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	880	0	1	04	01	H2001_880_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	881	0	1	04	01	H2001_881_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	882	0	1	04	01	H2001_882_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	883	0	1	04	01	H2001_883_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	884	0	1	04	01	H2001_884_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	886	0	1	04	01	H2001_886_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	887	0	1	04	01	H2001_887_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	888	0	1	04	01	H2001_888_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	889	0	1	04	01	H2001_889_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	890	0	1	04	01	H2001_890_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	891	0	1	04	01	H2001_891_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	892	0	1	04	01	H2001_892_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	893	0	1	04	01	H2001_893_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	894	0	1	04	01	H2001_894_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	895	0	1	04	01	H2001_895_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	896	0	1	04	01	H2001_896_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2001	897	0	1	04	01	H2001_897_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2029	801	0	1	04	01	H2029_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	802	0	1	04	01	H2029_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	805	0	2	04	01	H2029_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	806	0	2	04	01	H2029_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	809	0	1	04	01	H2029_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	810	0	1	04	01	H2029_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	811	0	1	04	01	H2029_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	812	0	1	04	01	H2029_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	815	0	1	04	01	H2029_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	816	0	1	04	01	H2029_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	821	0	1	04	01	H2029_821_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2029	822	0	1	04	01	H2029_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2032	001	0	1	04	01	H2032_001_0	8	2				2				2				2		2	2	1	2	3500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	3		0	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		0	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		0	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H2032	002	0	1	04	01	H2032_002_0	10	2				2				2				2		2	2	1	2	3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H2032	003	0	1	04	01	H2032_003_0	10	2				2				2				2		2	2	1	2	3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H2032	004	0	1	04	01	H2032_004_0	10	2				2				2				2		2	2	1	2	3500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	3		0	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		0	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		0	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H2032	801	0	1	04	01	H2032_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2032	802	0	1	04	01	H2032_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2032	803	0	1	04	01	H2032_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2032	804	0	1	04	01	H2032_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2034	001	0	1	01	01	H2034_001_0	5	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H2035	001	0	1	01	01	H2035_001_0	6	2				1	20	20	20	2				2		1	1	2					2														2		2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																												2						2					2		2	2	1	6	Restorative Crowns - 1 per tooth every 7 calendar years.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Prosthodontics - Rebases for full or partial dentures covered once every 2 calendar years. Replacement of all teeth & acrylic on cast metal frame covered once every 3 calendar years.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges) - 1 per tooth every 7 calendar years.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	One consultation is covered every calendar year.	2				1	0.00	0.00	0.00	1	2
H2041	001	0	1	01	01	H2041_001_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	002	0	1	01	01	H2041_002_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	003	0	1	01	01	H2041_003_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	004	0	1	01	01	H2041_004_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	005	0	1	01	01	H2041_005_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	006	0	1	01	01	H2041_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	007	0	1	01	01	H2041_007_0	6	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	008	0	1	01	01	H2041_008_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	009	0	1	01	01	H2041_009_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	010	0	1	01	01	H2041_010_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2041	011	0	1	01	01	H2041_011_0	7	2				1	30	30	30	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	012	0	1	01	01	H2041_012_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	013	0	1	01	01	H2041_013_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	014	0	1	01	01	H2041_014_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	015	0	1	01	01	H2041_015_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2041	016	0	1	01	01	H2041_016_0	7	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2056	003	0	1	02	01	H2056_003_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2056	005	0	1	02	01	H2056_005_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2056	801	0	1	01	01	H2056_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2056	802	0	1	01	01	H2056_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2064	001	0	1	20	08	H2064_001_0	3																																																																																																																																																																																																																																																																																																		
H2064	002	0	1	20	08	H2064_002_0	3																																																																																																																																																																																																																																																																																																		
H2085	001	0	1	20	08	H2085_001_0	2																																																																																																																																																																																																																																																																																																		
H2085	002	0	1	20	08	H2085_002_0	2																																																																																																																																																																																																																																																																																																		
H2108	022	0	1	01	01	H2108_022_0	7	2				2				1	55.00	55.00	55.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2																																2	1				2				2				2	2																																																																																											2	1				2				2				2	2
H2108	029	0	1	01	01	H2108_029_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	030	0	1	01	01	H2108_030_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2																																2	1				2				2				2	2																																																																																											2	1				2				2				2	2
H2108	036	0	1	01	01	H2108_036_0	6	2				2				1	55.00	55.00	55.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2																																2	1				2				2				2	2																																																																																											2	1				2				2				2	2
H2108	041	0	1	01	01	H2108_041_0	6	2				1	20	20	20	2				2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H2108	042	1	1	01	01	H2108_042_1	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1350.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	042	2	1	01	01	H2108_042_2	6	2				2				1	20.00	20.00	20.00	2		1	2	1		3600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	044	0	1	01	01	H2108_044_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1150.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	045	0	1	01	01	H2108_045_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1150.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2108	801	0	1	01	01	H2108_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2109	001	0	1	20	08	H2109_001_0	2																																																																																																																																																																																																																																																																																																		
H2109	002	0	1	20	08	H2109_002_0	2																																																																																																																																																																																																																																																																																																		
H2117	001	0	1	04	01	H2117_001_0	8	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2117	002	0	1	04	01	H2117_002_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2117	003	0	1	04	01	H2117_003_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2126	001	0	1	01	01	H2126_001_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2162	801	0	1	02	01	H2162_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2168	001	0	1	01	01	H2168_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	6	Periodic Oral evaluation 2 every 6 monthsLimited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months, by report.	2				2				2	2	2	2	1	6	Intraoral, complete series or panoramic x-ray 1 every 36 months.  Intraoral, periapical  - 3 every 6 months; Intraoral, periapical 6 times every 12 months. Sialography - 2 every week	2				2				2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	covered up to age of 20	2				2				2	2	2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.	2				2				2	2	2						2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.	2				2				1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime.	2				2				1	1	2	2	1	6	Gingivectomy or gingivopIasty - 1 every 12 months, per quad by report. Crown lengthening - 1 per tooth per ifetime.Periodontal scaling and root planing - 1 every 24 months per site/quad.Periodontal maintenance  once every 6 months.	2				2				1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).	2				2				1	2																2	2	1	6	Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.	2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2	2	2	1	6	Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime. Other Oral and Maxillofacial Surgery by report.	2				2				1	1																2	2	1	6	Palliative emergency treatment 2 every 12 months (Not reimbursable in addition to other therapeutic services performedat the same visit or in conjunction with initial or periodic oral examinations).  Deep sedation maximum of 60 minutes or 4 units.	2				2				1	2
H2168	002	0	1	01	01	H2168_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	6	Periodic Oral evaluation 2 every 6 monthsLimited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months, by report.	2				2				2	2	2	2	1	6	Intraoral, complete series or panoramic x-ray 1 every 36 months.  Intraoral, periapical - 3 every 6 months; Intraoral, periapical 6 times every 12 months. Sialography - 2 every week	2				2				2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	Covered up to age of 20	2				2				2	2	2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.	2				2				2	2	2						2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.	2				2				1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime.	2				2				1	1	2	2	1	6	Gingivectomy or gingivopIasty - 1 every 12 months, per quad by report. Crown lengthening - 1 per tooth per ifetime.Periodontal scaling and root planing - 1 every 24 months per site/quad.Periodontal maintenance  once every 6 months.	2				2				1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).	2				2				1	2																2	2	1	6	Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.	2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2	2	2	1	6	Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime.   Other Oral and Maxillofacial Surgery by report.	2				2				1	1																2	2	1	6	Palliative emergency treatment 2 every 12 months (Not reimbursable in addition to other therapeutic services performedat the same visit or in conjunction with initial or periodic oral examinations).  Deep sedation maximum of 60 minutes or 4 units.	2				2				1	2
H2168	004	0	1	01	01	H2168_004_0	4	2				1	20	20	20	2				2		2	2	1		1800.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	6	Sialography, complete series or panoramic x-ray 1 every 3 calendar years. Bitewings - 4 every calendar year.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Diagnostic casts, Viral culture & Unspecified preventive procedure 1 every calendar year	2				2				1	2	1	1					2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 3 calendar years.Crown services - 1 per tooth - every 5 calendar years.	2				2				2	2	2	2	1	6	1 per tooth in a lifetime	2				2				2	2	2	2	1	6	Gingivectomy, Periodontal scaling and root planing 1 per site/quad every 2 calendar years Crown lengthening 1 per tooth in a life time	2				2				2	2	2	2	1	6	Complete /Partial denture - 1 every 5 calendar year, per arch.Denture Adjustment - 1 every calendar year, per arch	2				2				2	2																															2	2	1	6	1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	Alveoloplasty 1 per site / quad every 5 calendar years	2				2				2	2																2	2	1	6	Palliative emergency treatment 1 every Calendar year. Consultation 1 every 6 months	2				2				2	2
H2172	001	0	1	02	01	H2172_001_0	5	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					3	111111		0.00	30.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	30.00	30.00	30.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	002	0	1	02	01	H2172_002_0	4	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					3	111111		0.00	30.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	30.00	30.00	30.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	005	0	1	01	01	H2172_005_0	3	2				2				1	40.00	40.00	40.00	2		1	1	2					2				2					3	111111		0.00	40.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	40.00	40.00	40.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	008	0	1	02	01	H2172_008_0	4	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					3	111111		0.00	30.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	30.00	30.00	30.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	009	0	1	02	01	H2172_009_0	4	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					3	111111		0.00	30.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	30.00	30.00	30.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	010	0	1	02	01	H2172_010_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					3	111111		0.00	35.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	35.00	35.00	35.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	013	0	1	02	01	H2172_013_0	4	2				2				1	40.00	40.00	40.00	2		1	1	2					2				2					3	111111		0.00	40.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		2000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	40.00	40.00	40.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	014	0	1	02	01	H2172_014_0	5	2				2				1	45.00	45.00	45.00	2		1	1	2					2				2					3	111111		0.00	45.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	45.00	45.00	45.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	016	0	1	01	01	H2172_016_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				1	111111	20	20	20	1	111111	0.00	0.00	0.00	2		2	2	2	3										2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.									2	2	2	1												2	2	2	2	2	3										2	2	2	2	1	3										2	2	2	1												2	2	1	1					2					2		2	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	1	20	20	20	1	0.00	0.00	0.00	1	1																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	017	0	1	01	01	H2172_017_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				1	111111	20	20	20	1	111111	0.00	0.00	0.00	2		2	2	2	3										2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.									2	2	2	1												2	2	2	2	2	3										2	2	2	2	1	3										2	2	2	1												2	2	1	1					2					2		2	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	1	20	20	20	1	0.00	0.00	0.00	1	1																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	018	0	1	01	01	H2172_018_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2				2					3	111111		0.00	30.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	1					2					2		2	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	2				3		0.00	30.00	1	1																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	019	0	1	01	01	H2172_019_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2				2					3	111111		0.00	30.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	1					2					2		2	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Extractions are limited to one per tooth.	2				3		0.00	30.00	1	1																2	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	2				1	0.00	0.00	0.00	1	2
H2172	020	0	1	02	01	H2172_020_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					3	111111		0.00	35.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	35.00	35.00	35.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	021	0	1	02	01	H2172_021_0	5	2				2				1	40.00	40.00	40.00	2		1	1	2					2				2					3	111111		0.00	40.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	40.00	40.00	40.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	022	0	1	02	01	H2172_022_0	5	2				2				1	40.00	40.00	40.00	2		1	1	2					2				2					3	111111		0.00	40.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	40.00	40.00	40.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	023	0	1	02	01	H2172_023_0	5	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					3	111111		0.00	35.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	35.00	35.00	35.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	024	0	1	02	01	H2172_024_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					3	111111		0.00	35.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		1000.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	35.00	35.00	35.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	025	0	1	01	01	H2172_025_0	5	2				2				1	40.00	40.00	40.00	2		1	1	2					2				2					3	111111		0.00	40.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	40.00	40.00	40.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	026	0	1	01	01	H2172_026_0	5	2				2				1	45.00	45.00	45.00	2		1	1	2					2				2					3	111111		0.00	45.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2																																																																																																																																																																			
H2172	027	0	1	02	01	H2172_027_0	4	2				2				1	40.00	40.00	40.00	2		1	1	2					2				2					3	111111		0.00	40.00	2		2	2	2	3		2								2	2	2	2	1	6	Preventive dental plan intraoral series limited to one per three years. Bitewings limited to one set per year.	2								2	2	2	1				2								2	2	2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				2								2	2	1	2		500.00	3		2					2		4	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	4	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	4	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	4	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															4	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	4	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	1	40.00	40.00	40.00	1	1																4	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2
H2172	801	0	1	01	01	H2172_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2172	805	0	1	01	01	H2172_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2172	806	0	2	01	01	H2172_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2174	001	0	1	02	01	H2174_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2174	012	0	1	02	01	H2174_012_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2174	013	0	1	02	01	H2174_013_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2185	001	0	1	01	01	H2185_001_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H2185	003	0	1	02	01	H2185_003_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3500.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H2218	001	0	1	20	08	H2218_001_0	2																																																																																																																																																																																																																																																																																																		
H2218	002	0	1	20	08	H2218_002_0	2																																																																																																																																																																																																																																																																																																		
H2219	001	0	1	20	08	H2219_001_0	5																																																																																																																																																																																																																																																																																																		
H2219	002	0	1	20	08	H2219_002_0	5																																																																																																																																																																																																																																																																																																		
H2220	001	0	1	20	08	H2220_001_0	3																																																																																																																																																																																																																																																																																																		
H2220	002	0	1	20	08	H2220_002_0	3																																																																																																																																																																																																																																																																																																		
H2221	001	0	1	20	08	H2221_001_0	2																																																																																																																																																																																																																																																																																																		
H2221	002	0	1	20	08	H2221_002_0	2																																																																																																																																																																																																																																																																																																		
H2222	002	0	1	20	08	H2222_002_0	2																																																																																																																																																																																																																																																																																																		
H2222	003	0	1	20	08	H2222_003_0	2																																																																																																																																																																																																																																																																																																		
H2223	001	0	1	20	08	H2223_001_0	2																																																																																																																																																																																																																																																																																																		
H2223	002	0	1	20	08	H2223_002_0	2																																																																																																																																																																																																																																																																																																		
H2224	001	0	1	01	01	H2224_001_0	11	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	6	2 periodic oral evaluation per year.2 limited oral evaluation per year1 Comprehensive oral or periodontal evaluation per calendar year.  1 per provider per lifetime	2				2				2	2	2	2	1	6	1 intraoral comprehensive series of radiographic images per 3 years.12 of intraoral-periapical first and each additional radiographic image per 12 months1 of panoramic radiographic image per 3 years.2 bitewings (1-4 images) per year.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	1	6	1 of topical application of fluoride or fluoride varnish every 90 days	2				2				1	2	2	2	1	6	2 per application of caries arresting medicament per lifetime, per tooth	2				2				2	2	2						2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	Root canals-1 per lifetime per toothApicoectomy-1 per lifetime per tooth	2				2				1	2	2	2	1	6	Gingivectomy or gingivolplasty-1 per 3 years per quadrantPeriodontal scaling and root planing-1 per 3 years per quadrantScaling in presence of generalized moderat or severy gingival inflammation-2 per year.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				2	2																															2	2	1	6	Medical Necessity	2				2				1	2	2	2	1	6	Alveoplasty-1 per 6 months per quadrantRemoval of exostosis-per site-1 per lifetime per archRemoval of torus palatinus-1 per lifetime per archRemoval of torus mandibularis-1 per lifetime per arch.Frenectomy-1 per lifteime per archFrenulectomy or frenuloplasty-1 per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment- Other non-emergency medically necessarytreatment may be provided during thesame visit.house/ extended care facility observation - One of (D9410) per 1 Day(s)Per Business,Per facility.	2				2				1	2
H2224	003	0	1	01	01	H2224_003_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	6	2 periodic oral evaluation per year.2 limited oral evaluation per year1 Comprehensive oral or periodontal evaluation per calendar year.  1 per provider per lifetime	2				2				2	2	2	2	1	6	1 intraoral comprehensive series of radiographic images per 3 years.12 of intraoral-periapical first and each additional radiographic image per 12 months1 of panoramic radiographic image per 3 years.2 bitewings (1-4 images) per year.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	1	6	1 of topical application of fluoride or fluoride varnish every 90 days	2				2				1	2	2	2	1	6	2 per application of caries arresting medicament per lifetime, per tooth	2				2				2	2	2						2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	Root canals-1 per lifetime per toothApicoectomy-1 per lifetime per tooth	2				2				1	2	2	2	1	6	Gingivectomy or gingivolplasty-1 per 3 years per quadrantPeriodontal scaling and root planing-1 per 3 years per quadrantScaling in presence of generalized moderat or severy gingival inflammation-2 per year.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				2	2																															2	2	1	6	Medical Necessity	2				2				1	2	2	2	1	6	Alveoplasty-1 per 6 months per quadrantRemoval of exostosis-per site-1 per lifetime per archRemoval of torus palatinus-1 per lifetime per archRemoval of torus mandibularis-1 per lifetime per arch.Frenectomy-1 per lifteime per archFrenulectomy or frenuloplasty-1 per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment- Other non-emergency medically necessarytreatment may be provided during thesame visit.house/ extended care facility observation - One of (D9410) per 1 Day(s)Per Business,Per facility.	2				2				1	2
H2225	001	0	1	01	01	H2225_001_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Full mouth services of radiographs (FMX) 1 every 3 calendar years, Bitewing Radiographs 1 per calendar year, Panoramic Radiograph 1 every 3 years. Cone Beam scan 1 every 84 months.	2				2				2	2	2	2	1	6	As medically necessary. Additional services may require prior authorization.	2				2				1	2	2	2	4	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	1 mouthguard every 24 months	2				2				2	2	2						2					2		2	2	1	6	As medically necessary	2				2				1	2	2	2	1	6	As medically necessary	2				2				1	2	2	2	1	6	Perio maintenance covered 4 per calendar year. Additional services may be covered as medically necessary.	2				2				2	2	2	2	1	6	Complete and Partial Dentures 1 per 60 months, Immediate dentures 1 per lifetime.	2				2				2	2																2	2	1	6	The plan covers 4 implants per year. 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	1 per 60 months	2				2				1	2	2	2	1	6	As medically necessary	2				2				2	2																2	2	1	6	Palliative treatment of dental pain per visit	2				2				2	2
H2226	001	0	1	01	01	H2226_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime  to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimted.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per code per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per 2 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities for each service in this category is unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service ranging from 1 per code per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H2226	003	0	1	01	01	H2226_003_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime  to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimted.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per code per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per 2 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities for each service in this category is unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 3 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service ranging from 1 per code per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H2230	002	0	1	04	01	H2230_002_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2230	018	1	1	04	01	H2230_018_1	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	500.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1					2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c4 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c5 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c6 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c7 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c8 for comprehensive list.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2230	018	2	1	04	01	H2230_018_2	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	500.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1					2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c4 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c5 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c6 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c7 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c8 for comprehensive list.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2230	019	0	1	04	01	H2230_019_0	6	2				2				1	55.00	55.00	55.00	2		2	2	1	2	500.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1					2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c4 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c5 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c6 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c7 for comprehensive list	1	50	50	50	2				2	2	2	2	1	6	See Notes Section for 16c8 for comprehensive list	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2230	801	0	1	04	01	H2230_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2230	809	0	1	04	01	H2230_809_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2230	813	0	1	04	01	H2230_813_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2235	001	0	1	01	01	H2235_001_0	8	2				2				3		15.00	150.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	1	6	See note below.	2				2				2	2	2	2	1	6	See note below.	2				2				2	2																2	2	2	6	A member is limited to two of any combination of the following: Scaling in the presence of generalized moderate or severe gingival inflammation, periodontal maintenance and prophylaxis.	2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	See note below.	3		0	50	2				1	1	2	2	2	3		2				2				1	1	2	2	2	6	See note below.	2				2				1	1	2	2	1	6	See note below.	3		0	50	2				1	1																															2	2	1	6	See note below.	1	50	50	50	2				1	1	2	2	1	6	Two extractions  every calendar year One extraction per tooth per lifetime	2				2				1	1																														
H2235	002	0	1	01	01	H2235_002_0	8	2				2				3		25.00	200.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	1	6	See note below.	2				2				2	2	2	2	1	6	See note below.	2				2				2	2																2	2	2	6	A member is limited to two of any combination of the following: Scaling in the presence of generalized moderate or severe gingival inflammation, periodontal maintenance and prophylaxis.	2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	See note below.	3		0	50	2				1	1	2	2	2	3		2				2				1	1	2	2	2	6	See note below.	2				2				1	1	2	2	1	6	See note below.	3		0	50	2				1	1																															2	2	1	6	See note below.	1	50	50	50	2				1	1	2	2	1	6	Two extractions  every calendar year One extraction per tooth per lifetime	2				2				1	1																														
H2235	003	0	1	01	01	H2235_003_0	8	2				2				3		25.00	175.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	1	6	See note below.	2				2				2	2	2	2	1	6	See note below.	2				2				2	2																2	2	2	6	A member is limited to two of any combination of the following: Scaling in the presence of generalized moderate or severe gingival inflammation, periodontal maintenance and prophylaxis.	2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	See note below.	3		0	50	2				1	1	2	2	2	3		2				2				1	1	2	2	2	6	See note below.	2				2				1	1	2	2	1	6	See note below.	3		0	50	2				1	1																															2	2	1	6	See note below.	1	50	50	50	2				1	1	2	2	1	6	Two extractions  every calendar year One extraction per tooth per lifetime	2				2				1	1																														
H2237	007	0	1	01	01	H2237_007_0	3	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	6	crown recement 1/5 yrs, crown 1/tooth/lifetime, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	2	6	bridge recement, bridges 1/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service unl/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H2247	001	0	1	02	01	H2247_001_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2247	003	0	1	02	01	H2247_003_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2247	004	0	1	01	01	H2247_004_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2247	005	0	1	01	01	H2247_005_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2256	001	1	1	01	01	H2256_001_1	9	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	001	2	1	01	01	H2256_001_2	8	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	001	6	1	01	01	H2256_001_6	9	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	015	1	1	01	01	H2256_015_1	9	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	015	2	1	01	01	H2256_015_2	9	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	015	6	1	01	01	H2256_015_6	9	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	016	1	1	01	01	H2256_016_1	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	016	2	1	01	01	H2256_016_2	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	018	1	1	01	01	H2256_018_1	9	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	018	7	1	01	01	H2256_018_7	8	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	018	8	1	01	01	H2256_018_8	8	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	019	1	1	01	01	H2256_019_1	7	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	019	7	1	01	01	H2256_019_7	7	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	026	1	1	01	01	H2256_026_1	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	026	2	1	01	01	H2256_026_2	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	026	3	1	01	01	H2256_026_3	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	033	0	1	01	01	H2256_033_0	9	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	034	0	1	01	01	H2256_034_0	9	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	036	0	1	01	01	H2256_036_0	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	039	0	1	01	01	H2256_039_0	7	2				2				1	15.00	15.00	15.00	2		1	1																																																																																																																																																																																																																																																																																		
H2256	040	0	1	01	01	H2256_040_0	7	2				2				1	25.00	25.00	25.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	041	0	1	01	01	H2256_041_0	7	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	042	0	1	01	01	H2256_042_0	7	2				2				1	40.00	40.00	40.00	2		1	1	1		1000.00	3		2				2					2					2		4	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	50	2				2	2	4	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	50	2				2	2																4	2	2	3		2				2				2	2																															1	1					2					2		4	2	1	6	Covers 1 amalgam or resin composite filling, per surface per tooth, per 24 months.	1	50	50	50	2				2	2	3													2	2	4	2	4	6	Covers up to 4 visits per yr: in lieu of cleaning, 1 periodontal cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling & root planing, per quadrant, per 24 mos & 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	3													2	2																															3													2	2	4	2	1	6	Covers 1 simple extraction per tooth.	1	50	50	50	2				2	2																4	2	1	6	Covers 1 minor treatment for pain relief when only exam and X-ray(s) performed on the same date of service.	1	50	50	50	2				2	2
H2256	046	0	1	01	01	H2256_046_0	9	2				2				1	40.00	40.00	40.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	2	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	2	2	3	6	Covers 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	2	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	1	50	50	50	2				2	2	2	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															2	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	2	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	1	50	50	50	2				2	2																2	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2
H2256	801	0	1	01	01	H2256_801_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2256	802	0	1	01	01	H2256_802_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2256	803	0	1	01	01	H2256_803_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2256	808	0	1	01	01	H2256_808_0	4	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2261	005	0	1	01	01	H2261_005_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	One set of bitewings twice per calendar year.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2261	022	1	1	01	01	H2261_022_1	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	One set of bitewings twice per calendar year.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2261	022	2	1	01	01	H2261_022_2	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	One set of bitewings twice per calendar year.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2261	023	1	1	02	01	H2261_023_1	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2261	023	2	1	02	01	H2261_023_2	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2261	024	0	1	02	01	H2261_024_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		500.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	7	6	Full mouth X-rays, 7 or more films, or panoramic X-ray with bitewing X-rays once every 60 months. Bitewing X-rays once every 6 months. Single-tooth X-rays as needed.	2				2				2	2	2	2	1	6	Study models and casts used in planning treatment, once each 60 months	2				2				2	2	2	2	3	3		2				2				2	2																															1	1					2					2		2	2	1	6	Silver and white fillings: once per tooth in 12 months. Inlays: once per tooth in 60 months.	1	50	50	50	2				2	2	2	2	1	6	Root canals and retreatment of prior root canal on permanent teeth: once per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planning: once per quadrant per 24 months. Periodontal Surgery: once per quadrant per 36 months. Maintenance following active periodontal therapy: once within three months	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c4 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c5 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See notes for 16c6 for a comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c7 for comprehensive list.	1	50	50	50	2				2	2	2	2	1	6	See Notes for 16c8 for comprehensive list.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H2261	801	0	1	01	01	H2261_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2261	809	0	1	01	01	H2261_809_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2272	001	0	1	02	01	H2272_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2272	003	0	1	02	01	H2272_003_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2292	001	0	1	04	01	H2292_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2292	002	0	1	04	01	H2292_002_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2293	001	0	1	04	01	H2293_001_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	002	0	1	04	01	H2293_002_0	2	2				1	20	20	20	2				2		1	2	1	2	1750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2293	004	0	1	04	01	H2293_004_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2293	009	0	1	04	01	H2293_009_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	010	0	1	04	01	H2293_010_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	014	0	1	04	01	H2293_014_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	016	0	1	04	01	H2293_016_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H2293	017	0	1	04	01	H2293_017_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	019	0	1	04	01	H2293_019_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	021	0	1	04	01	H2293_021_0	2	2				1	20	20	20	2				2		1	2	1	2	1750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2293	023	0	1	04	01	H2293_023_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	025	0	1	04	01	H2293_025_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	026	0	1	04	01	H2293_026_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H2293	029	0	1	04	01	H2293_029_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	031	0	1	04	01	H2293_031_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	033	0	1	04	01	H2293_033_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2293	035	0	1	04	01	H2293_035_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2318	001	0	1	20	08	H2318_001_0	2																																																																																																																																																																																																																																																																																																		
H2318	002	0	1	20	08	H2318_002_0	2																																																																																																																																																																																																																																																																																																		
H2320	022	1	1	02	01	H2320_022_1	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H2320	022	2	1	02	01	H2320_022_2	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H2320	022	3	1	02	01	H2320_022_3	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H2320	022	4	1	02	01	H2320_022_4	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H2320	022	5	1	02	01	H2320_022_5	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H2320	028	1	1	02	01	H2320_028_1	6	2				2				3		0.00	175.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	2	1	02	01	H2320_028_2	6	2				2				3		0.00	175.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	3	1	02	01	H2320_028_3	6	2				2				3		0.00	175.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	4	1	02	01	H2320_028_4	6	2				2				3		0.00	175.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	028	5	1	02	01	H2320_028_5	6	2				2				3		0.00	175.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	029	1	1	02	01	H2320_029_1	6	2				2				3		0.00	325.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia when used in conjunction with qualifying dental services.	2				2				2	2
H2320	029	2	1	02	01	H2320_029_2	6	2				2				3		0.00	325.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia when used in conjunction with qualifying dental services.	2				2				2	2
H2320	029	3	1	02	01	H2320_029_3	6	2				2				3		0.00	325.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia when used in conjunction with qualifying dental services.	2				2				2	2
H2320	029	4	1	02	01	H2320_029_4	6	2				2				3		0.00	325.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia when used in conjunction with qualifying dental services.	2				2				2	2
H2320	029	5	1	02	01	H2320_029_5	6	2				2				3		0.00	325.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2		2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia when used in conjunction with qualifying dental services.	2				2				2	2
H2320	031	0	1	02	01	H2320_031_0	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	032	1	1	02	01	H2320_032_1	5	2				2				3		0.00	450.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	032	2	1	02	01	H2320_032_2	5	2				2				3		0.00	450.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	032	5	1	02	01	H2320_032_5	5	2				2				3		0.00	450.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H2320	802	0	1	02	01	H2320_802_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	803	0	1	02	01	H2320_803_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	804	0	1	01	01	H2320_804_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	805	0	1	01	01	H2320_805_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	810	0	1	01	01	H2320_810_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	811	0	1	01	01	H2320_811_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	812	0	1	02	01	H2320_812_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	813	0	1	02	01	H2320_813_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	814	0	1	01	01	H2320_814_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	815	0	1	01	01	H2320_815_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	816	0	1	01	01	H2320_816_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2320	817	0	1	01	01	H2320_817_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2322	008	0	1	04	01	H2322_008_0	7	2				2				3		0.00	25.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2322	011	0	1	04	01	H2322_011_0	7	2				2				3		0.00	45.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	Per Lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2322	016	0	1	04	01	H2322_016_0	6	2				2				3		0.00	40.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2322	017	0	1	04	01	H2322_017_0	7	2				2				3		0.00	30.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	2				2				2	2	2	2	1	6	per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2322	020	0	1	04	01	H2322_020_0	6	2				1	20	20	20	2				2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	2		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	2				2				2	2	2	2	1	6	per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2322	801	0	1	04	01	H2322_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2322	803	0	1	04	01	H2322_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2354	015	0	1	01	01	H2354_015_0	6	2				2				3		0.00	45.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2354	018	0	1	01	01	H2354_018_0	7	2				2				3		0.00	50.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2354	019	0	1	01	01	H2354_019_0	5	2				2				3		0.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2354	021	0	1	02	01	H2354_021_0	7	2				2				3		0.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2354	025	0	1	01	01	H2354_025_0	7	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	every 5 years	2				2				2	2	2	2	1	6	Per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2354	028	0	1	01	01	H2354_028_0	6	2				2				3		0.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	1	50	50	50	2				2	2	2	2	1	6	per lifetime	1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	2	1				3		0	50	2				2	2																														
H2354	029	0	1	01	01	H2354_029_0	7	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years	2				2				2	2	2	2	1	6	per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2354	030	0	1	01	01	H2354_030_0	7	2				2				3		0.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing Xrays are covered once per calendar year. Full mouth Xrays or Panoramic Xrays are covered once per 5 year period. Full mouth and Bitewing Xrays are not payable in the same year. Must use Delta Dental.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	every 5 years	2				2				2	2	2	2	1	6	Per lifetime	2				2				2	2	2	2	2	3		2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2354	801	0	1	01	01	H2354_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2354	802	0	1	02	01	H2354_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2368	001	0	1	20	08	H2368_001_0	2																																																																																																																																																																																																																																																																																																		
H2368	002	0	1	20	08	H2368_002_0	2																																																																																																																																																																																																																																																																																																		
H2384	001	0	1	20	08	H2384_001_0	2																																																																																																																																																																																																																																																																																																		
H2384	002	0	1	20	08	H2384_002_0	2																																																																																																																																																																																																																																																																																																		
H2385	001	0	1	04	01	H2385_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2385	002	0	1	04	01	H2385_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2385	003	0	1	04	01	H2385_003_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2385	004	0	1	04	01	H2385_004_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2386	001	0	1	20	08	H2386_001_0	2																																																																																																																																																																																																																																																																																																		
H2386	002	0	1	20	08	H2386_002_0	2																																																																																																																																																																																																																																																																																																		
H2392	001	0	1	01	01	H2392_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2392	003	0	1	01	01	H2392_003_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2397	001	0	1	20	08	H2397_001_0	2																																																																																																																																																																																																																																																																																																		
H2397	002	0	1	20	08	H2397_002_0	2																																																																																																																																																																																																																																																																																																		
H2400	001	0	1	01	01	H2400_001_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2
H2400	002	0	1	01	01	H2400_002_0	5	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2400.00	3		2					2		2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2
H2406	008	0	1	04	01	H2406_008_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	009	0	1	04	01	H2406_009_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	010	0	1	04	01	H2406_010_0	9	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	011	0	1	04	01	H2406_011_0	9	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	013	0	1	04	01	H2406_013_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	015	0	1	04	01	H2406_015_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	016	0	1	04	01	H2406_016_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	017	0	1	04	01	H2406_017_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	018	0	1	04	01	H2406_018_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	019	0	1	04	01	H2406_019_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	034	0	1	04	01	H2406_034_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	035	0	1	04	01	H2406_035_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	036	0	1	04	01	H2406_036_0	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	037	0	1	04	01	H2406_037_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	038	0	1	04	01	H2406_038_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	039	0	1	04	01	H2406_039_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	040	0	1	04	01	H2406_040_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	041	0	1	04	01	H2406_041_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	042	0	1	04	01	H2406_042_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	043	0	1	04	01	H2406_043_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	044	0	1	04	01	H2406_044_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	046	0	1	04	01	H2406_046_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	047	0	1	04	01	H2406_047_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	048	0	1	04	01	H2406_048_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	050	0	1	04	01	H2406_050_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2406	052	0	1	04	01	H2406_052_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	053	0	1	04	01	H2406_053_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2406	054	0	1	04	01	H2406_054_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	055	0	1	04	01	H2406_055_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	056	0	1	04	01	H2406_056_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	058	0	1	04	01	H2406_058_0	6	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	059	0	1	04	01	H2406_059_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	062	0	1	04	01	H2406_062_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	063	0	1	04	01	H2406_063_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	065	0	1	04	01	H2406_065_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	066	0	1	04	01	H2406_066_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	067	0	1	04	01	H2406_067_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	068	0	1	04	01	H2406_068_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	069	0	1	04	01	H2406_069_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	070	0	1	04	01	H2406_070_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	071	0	1	04	01	H2406_071_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	072	0	1	04	01	H2406_072_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	073	0	1	04	01	H2406_073_0	3	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	074	0	1	04	01	H2406_074_0	3	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	075	0	1	04	01	H2406_075_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	076	0	1	04	01	H2406_076_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	077	0	1	04	01	H2406_077_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	078	0	1	04	01	H2406_078_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	080	0	1	04	01	H2406_080_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	082	0	1	04	01	H2406_082_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	087	0	1	04	01	H2406_087_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	088	0	1	04	01	H2406_088_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	089	0	1	04	01	H2406_089_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	090	0	1	04	01	H2406_090_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	091	0	1	04	01	H2406_091_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	092	0	1	04	01	H2406_092_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	093	0	1	04	01	H2406_093_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	094	0	1	04	01	H2406_094_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	096	0	1	04	01	H2406_096_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2406	097	0	1	04	01	H2406_097_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2406	098	0	1	04	01	H2406_098_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	099	0	1	04	01	H2406_099_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2406	100	0	1	04	01	H2406_100_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	101	0	1	04	01	H2406_101_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	104	0	1	04	01	H2406_104_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	110	0	1	04	01	H2406_110_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	112	0	1	04	01	H2406_112_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	113	0	1	04	01	H2406_113_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	115	0	1	04	01	H2406_115_0	4	2				1	20	20	20	2				2		1	2	1	2	1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	119	0	1	04	01	H2406_119_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	121	0	1	04	01	H2406_121_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	125	0	1	04	01	H2406_125_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	129	0	1	04	01	H2406_129_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	130	0	1	04	01	H2406_130_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2406	131	0	1	04	01	H2406_131_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2406	135	0	1	04	01	H2406_135_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2416	001	0	1	01	01	H2416_001_0	7	2				2				2				2		1	2																																																																																																																2						2					2		2	2	1	3		2				2				1	2																															2	2	1	6	Additional one replacement dentures per three years.	2				2				1	2																																																																																										
H2417	001	0	1	01	01	H2417_001_0	7	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H2419	001	0	1	01	01	H2419_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		2	2	1	3		2				2				2	2																																																																																																																																							
H2422	002	0	1	01	01	H2422_002_0	7	2				2				2				2		2	2																																																																																																																2						1	2	2500.00	3		2		2	1				2				2				2	2																																																																																																																																							
H2425	001	0	1	01	01	H2425_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2441	001	0	1	04	01	H2441_001_0	6	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2445	001	0	1	02	01	H2445_001_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2445	002	0	1	02	01	H2445_002_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2445	003	0	1	02	01	H2445_003_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2445	004	0	1	02	01	H2445_004_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2445	005	0	1	02	01	H2445_005_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2450	002	0	1	18	06	H2450_002_0	4	2				2				3		0.00	10.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	007	0	1	18	06	H2450_007_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2450	016	0	1	18	06	H2450_016_0	5	2				2				3		0.00	15.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	030	0	1	18	06	H2450_030_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2450	032	0	1	18	06	H2450_032_0	3	2				2				3		0.00	15.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	033	0	1	18	06	H2450_033_0	3	2				2				3		0.00	10.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	034	0	1	18	06	H2450_034_0	3	2				2				3		0.00	15.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	035	0	1	18	06	H2450_035_0	4	2				2				3		0.00	15.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	036	0	1	18	06	H2450_036_0	3	2				2				2				2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	037	0	1	18	06	H2450_037_0	4	2				2				2				2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	038	0	1	18	06	H2450_038_0	3	2				2				3		0.00	15.00	2		2	2	1		300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	039	0	1	18	06	H2450_039_0	4	2				2				3		0.00	15.00	2		2	2	1		300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	043	0	1	18	06	H2450_043_0	3	2				2				2				2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	044	0	1	18	06	H2450_044_0	3	2				2				3		15.00	60.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	046	0	1	18	06	H2450_046_0	3	2				2				3		10.00	25.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	049	0	1	18	06	H2450_049_0	4	2				2				3		15.00	60.00	2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	050	0	1	18	06	H2450_050_0	3	2				2				3		15.00	60.00	2		2	2																																																																																																																																																																																																																																																																																		
H2450	051	0	1	18	06	H2450_051_0	3	2				2				3		10.00	55.00	2		2	2	1		200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2450	801	0	1	18	06	H2450_801_0	2																																																																																																																																																																																																																																																																																																		
H2456	002	0	1	01	01	H2456_002_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2																																																													2						2					2		2	2	2	6	Restorative service is one crown procedure and one crown repair per year.	2				2				2	2																																																																																																																																							
H2458	002	0	1	01	01	H2458_002_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2461	005	0	1	18	06	H2461_005_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2461	006	0	1	18	06	H2461_006_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2461	007	0	1	18	06	H2461_007_0	2	2				2				2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2461	008	0	1	18	06	H2461_008_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2461	009	0	1	18	06	H2461_009_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	2 routine oral evaluations per calendar year, 1 Comprehensive Periodontal evaluation per 3 years, 1 detailed and extensive oral evaluation per 12 months, 1 combination consultation and a limited oral evaluation per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph per calendar year, or one full mouth radiograph series or intraoral tomosynthesis per calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2461	010	0	1	18	06	H2461_010_0	3	2				2				2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H2462	026	0	1	18	06	H2462_026_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2462	027	0	1	18	06	H2462_027_0	6	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H2462	028	0	1	18	06	H2462_028_0	8	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H2462	801	0	1	18	06	H2462_801_0	1																																																																																																																																																																																																																																																																																																		
H2462	802	0	1	18	06	H2462_802_0	1																																																																																																																																																																																																																																																																																																		
H2463	001	0	1	01	01	H2463_001_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2478	001	0	1	01	01	H2478_001_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H2486	003	0	1	01	01	H2486_003_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2486	005	0	1	01	01	H2486_005_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2486	007	0	1	01	01	H2486_007_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2486	801	0	1	01	01	H2486_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2486	802	0	1	01	01	H2486_802_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2486	805	0	1	01	01	H2486_805_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2486	806	0	1	01	01	H2486_806_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2491	010	0	1	02	01	H2491_010_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2491	017	0	1	02	01	H2491_017_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	025	0	1	02	01	H2491_025_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2491	028	0	1	02	01	H2491_028_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	029	0	1	02	01	H2491_029_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	030	0	1	02	01	H2491_030_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	031	0	1	02	01	H2491_031_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2491	032	1	1	02	01	H2491_032_1	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	032	2	1	02	01	H2491_032_2	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	033	1	1	02	01	H2491_033_1	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2491	033	2	1	02	01	H2491_033_2	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2509	001	0	1	02	01	H2509_001_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2509	002	0	1	02	01	H2509_002_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2509	003	0	1	02	01	H2509_003_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2526	001	0	1	04	01	H2526_001_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2526	002	0	1	04	01	H2526_002_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2526	003	0	1	04	01	H2526_003_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2541	001	0	1	20	08	H2541_001_0	2																																																																																																																																																																																																																																																																																																		
H2541	002	0	1	20	08	H2541_002_0	2																																																																																																																																																																																																																																																																																																		
H2563	020	0	1	01	01	H2563_020_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	6	2 of periodic oral or compehensive evaluation every 12 months1 comprehensive evluation per provider/location per 36 months3 of  limited or evaluation every 12 months	2				2				2	2	2	2	1	6	Please see notes section for description of x-ray coverage	2				2				2	2																2	2	2	6	2 visits/12 months	2				2				2	2	2	2	2	6	2 fluoride treatments per 12 months	2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H2564	001	0	1	01	01	H2564_001_0	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		3000.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H2593	001	0	1	02	01	H2593_001_0	4	2				2				3		0.00	35.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H2593	003	0	1	01	01	H2593_003_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	005	0	1	02	01	H2593_005_0	4	2				2				3		0.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	006	0	1	02	01	H2593_006_0	4	2				2				3		0.00	35.00	2		1	2	1		1200.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	029	0	1	02	01	H2593_029_0	5	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H2593	031	0	1	02	01	H2593_031_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	032	0	1	01	01	H2593_032_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	040	0	1	02	01	H2593_040_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	043	0	1	02	01	H2593_043_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	044	0	1	01	01	H2593_044_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	045	0	1	01	01	H2593_045_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	046	0	1	01	01	H2593_046_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	047	0	1	01	01	H2593_047_0	6	2				1	20	20	20	2				2		1	2	1		4500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	048	0	1	01	01	H2593_048_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	051	0	1	01	01	H2593_051_0	6	2				1	20	20	20	2				2		1	2	1		4250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2593	053	0	1	01	01	H2593_053_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2610	005	0	1	01	01	H2610_005_0	9	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		250.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	006	0	1	01	01	H2610_006_0	9	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	015	0	1	01	01	H2610_015_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		925.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	016	0	1	01	01	H2610_016_0	7	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2900.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	021	0	1	01	01	H2610_021_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1600.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	027	0	1	01	01	H2610_027_0	7	2				2				1	25.00	25.00	25.00	2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic film every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2610	803	0	1	01	01	H2610_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	804	0	1	01	01	H2610_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	805	0	1	01	01	H2610_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	806	0	1	01	01	H2610_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	807	0	1	02	01	H2610_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	808	0	1	02	01	H2610_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	809	0	1	02	01	H2610_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2610	810	0	1	02	01	H2610_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2624	001	0	1	01	01	H2624_001_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2		1500.00	3		2					1	100.00	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2
H2628	001	0	1	01	01	H2628_001_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	6	Periodic Oral evaluation 1 every yearComprehensive oral evaluation 1 every 5 years per providerComprehensive periodontal evaluation 1 every year	2				1	0.00	0.00	0.00	2	2	2	2	2	6	1 series of bitewing films every 6 months1 panoramic radiograph- 1 every 5 yearsComprehensive series of radiographic  images-1 every 5 years per provider	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT Capture- 1 every 5 years per providerDental and Facial Scan- By Report	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	2	6	Tobacco counseling, control prevention oral disease - 1 every 6 monthsOral health Substance abuse counseling- 1every 6 monthsCaries arrest treatment- 3 per tooth per year	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Amalgam/Resin Filings-unlimitedProtective/interim therapeutic restoration-1 every 6 mo., 5 per tooth per lifetimeCore buildup-1 per tooth per 6 mo.Pin retention-3 per tooth per lifetimeBand Stabilization-1 per tooth per lifetimeHydroxyapatite regeneration treatment-2 per tooth per yr. by report	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Gingivectomy- limited to correction of severe hyperplasia or hypertrophic gingivitisPeriodontal scaling and root planing- 1 per quad per 24 monthsPeriodontal maintenance-1 per year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Complete/Partial Dentures- 1 every 8 yearsDenture Reline- 1 every 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Unspecified maxillofacial prosthesis, by report medical necessity required	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to implant removal, guided tissue regeneration, and replacement of restorative material. Accessing and retorquing loose implant screw, by report.Implant and Implant healing therapy are covered unlimited and requires authorization based on medical necessity.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Tooth removal- 1 tooth per lifetimeAlveoloplasty with extractions- 1 per quad per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	First 15 min increment of general anesthesia & moderate analgesia- 1 per daySubsequent 15 min increment of general anesthesia & moderate analgesia- 4 per day	2				1	0.00	0.00	0.00	1	2
H2628	003	0	1	01	01	H2628_003_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	6	Periodic Oral evaluation 1 every yearComprehensive oral evaluation 1 every 5 years per providerComprehensive periodontal evaluation 1 every year	2				1	0.00	0.00	0.00	2	2	2	2	2	6	1 series of bitewing films every 6 months1 panoramic radiograph- 1 every 5 yearsComprehensive series of radiographic  images-1 every 5 years per provider	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT Capture- 1 every 5 years per providerDental and Facial Scan- By Report	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	2	6	Tobacco counseling, control prevention oral disease - 1 every 6 monthsOral health Substance abuse counseling- 1every 6 monthsCaries arrest treatment- 3 per tooth per year	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Amalgam/Resin Filings-unlimitedProtective/interim therapeutic restoration-1 every 6 mo., 5 per tooth per lifetimeCore buildup-1 per tooth per 6 mo.Pin retention-3 per tooth per lifetimeBand Stabilization-1 per tooth per lifetimeHydroxyapatite regeneration treatment-2 per tooth per yr. by report	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Gingivectomy- limited to correction of severe hyperplasia or hypertrophic gingivitisPeriodontal scaling and root planing- 1 per quad per 24 monthsPeriodontal maintenance-1 per year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Complete/Partial Dentures- 1 every 8 yearsDenture Reline- 1 every 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Unspecified maxillofacial prosthesis, by report medical necessity required	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to implant removal, guided tissue regeneration, and replacement of restorative material. Accessing and retorquing loose implant screw, by report.Implant and Implant healing therapy are covered unlimited and requires authorization based on medical necessity.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Tooth removal- 1 tooth per lifetimeAlveoloplasty with extractions- 1 per quad per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	First 15 min increment of general anesthesia & moderate analgesia- 1 per daySubsequent 15 min increment of general anesthesia & moderate analgesia- 4 per day	2				1	0.00	0.00	0.00	1	2
H2628	004	0	1	01	01	H2628_004_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	6	Periodic Oral evaluation 1 every yearComprehensive oral evaluation 1 every 5 years per providerComprehensive periodontal evaluation 1 every year	2				1	0.00	0.00	0.00	2	2	2	2	2	6	1 series of bitewing films every 6 months1 panoramic radiograph- 1 every 5 yearsComprehensive series of radiographic  images-1 every 5 years per provider	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT Capture- 1 every 5 years per providerDental and Facial Scan- By Report	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	2	6	Tobacco counseling, control prevention oral disease - 1 every 6 monthsOral health Substance abuse counseling- 1every 6 monthsCaries arrest treatment- 3 per tooth per year	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Amalgam/Resin Filings-unlimitedProtective/interim therapeutic restoration-1 every 6 mo., 5 per tooth per lifetimeCore buildup-1 per tooth per 6 mo.Pin retention-3 per tooth per lifetimeBand Stabilization-1 per tooth per lifetimeHydroxyapatite regeneration treatment-2 per tooth per yr. by report	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Gingivectomy- limited to correction of severe hyperplasia or hypertrophic gingivitisPeriodontal scaling and root planing- 1 per quad per 24 monthsPeriodontal maintenance-1 per year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Complete/Partial Dentures- 1 every 8 yearsDenture Reline- 1 every 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Unspecified maxillofacial prosthesis, by report medical necessity required	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Limited to implant removal, guided tissue regeneration, and replacement of restorative material. Accessing and retorquing loose implant screw, by report.Implant and Implant healing therapy are covered unlimited and requires authorization based on medical necessity.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Tooth removal- 1 tooth per lifetimeAlveoloplasty with extractions- 1 per quad per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	First 15 min increment of general anesthesia & moderate analgesia- 1 per daySubsequent 15 min increment of general anesthesia & moderate analgesia- 4 per day	2				1	0.00	0.00	0.00	1	2
H2628	005	0	1	01	01	H2628_005_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1800.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2630	001	0	1	01	01	H2630_001_0	7	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		22.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	58.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		0.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H2630	002	0	1	01	01	H2630_002_0	7	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		22.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	58.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		0.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H2663	005	0	1	02	01	H2663_005_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	006	0	1	02	01	H2663_006_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	017	0	1	02	01	H2663_017_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	021	0	1	02	01	H2663_021_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	022	0	1	02	01	H2663_022_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	023	0	1	02	01	H2663_023_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	025	0	1	02	01	H2663_025_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	026	0	1	02	01	H2663_026_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	028	0	1	02	01	H2663_028_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	029	0	1	02	01	H2663_029_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	034	0	1	01	01	H2663_034_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	038	0	1	02	01	H2663_038_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	039	0	1	01	01	H2663_039_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	040	0	1	02	01	H2663_040_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	041	0	1	02	01	H2663_041_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	042	0	1	01	01	H2663_042_0	2	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H2663	043	0	1	02	01	H2663_043_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	052	0	1	01	01	H2663_052_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	053	0	1	01	01	H2663_053_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	056	0	1	01	01	H2663_056_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	057	0	1	02	01	H2663_057_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	061	0	1	02	01	H2663_061_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	063	0	1	02	01	H2663_063_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	064	0	1	01	01	H2663_064_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	067	0	1	01	01	H2663_067_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	069	0	1	02	01	H2663_069_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	097	0	1	01	01	H2663_097_0	2	2				1	20	20	20	2				2		1	2	1		3750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	098	0	1	01	01	H2663_098_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	099	0	1	01	01	H2663_099_0	2	2				1	20	20	20	2				2		1	2	1		975.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H2663	100	0	1	01	01	H2663_100_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	102	0	1	01	01	H2663_102_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H2663	103	0	1	02	01	H2663_103_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H2663	805	0	1	01	01	H2663_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2686	004	1	1	04	01	H2686_004_1	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	004	3	1	04	01	H2686_004_3	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	005	1	1	04	01	H2686_005_1	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	005	2	1	04	01	H2686_005_2	6	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	006	1	1	04	01	H2686_006_1	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	006	2	1	04	01	H2686_006_2	5	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	007	0	1	04	01	H2686_007_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	008	0	1	04	01	H2686_008_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	009	0	1	04	01	H2686_009_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2686	010	0	1	04	01	H2686_010_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2687	001	0	1	01	01	H2687_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H2694	001	0	1	04	01	H2694_001_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2694	002	0	1	04	01	H2694_002_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H2697	001	0	1	01	01	H2697_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		1750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	002	0	1	01	01	H2697_002_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	003	0	1	01	01	H2697_003_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	004	0	1	01	01	H2697_004_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	006	0	1	01	01	H2697_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	007	0	1	01	01	H2697_007_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	009	0	1	01	01	H2697_009_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	010	0	1	01	01	H2697_010_0	9	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays twice per year and panoramic x-rays once every three years.	2				2				2	2	2	2	1	6	Plan covers tests and laboratory examinations, and coverage frequency varies.	2				2				2	2	2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2	2	2	2	6	Plan covers other preventive dental services, and coverage frequency varies. For example, plan covers counseling for control and prevention of oral disease twice per year.	2				2				2	2	1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2	2	2	1	6	Plan covers maxillofacial prosthetics and coverage frequency varies.	2				2				1	2	2	2	1	6	Plan covers accessing and retorquing loose implant screws. Coverage frequency varies.	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers othodontics, and coverage frequency varies. For example, comprehensive orthodontic treatment of the adolescent dentition, active treatment is covered at 1 calendar quarter per course of treatment.	2				2				1	2	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	011	0	1	01	01	H2697_011_0	9	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays twice per year and panoramic x-rays once every three years.	2				2				2	2	2	2	1	6	Plan covers tests and laboratory examinations, and coverage frequency varies.	2				2				2	2	2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2	2	2	2	6	Plan covers other preventive dental services, and coverage frequency varies. For example, plan covers counseling for control and prevention of oral disease twice per year.	2				2				2	2	1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2	2	2	1	6	Plan covers maxillofacial prosthetics and coverage frequency varies.	2				2				1	2	2	2	1	6	Plan covers accessing and retorquing loose implant screws. Coverage frequency varies.	2				2				1	2	2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers othodontics, and coverage frequency varies. For example, comprehensive orthodontic treatment of the adolescent dentition, active treatment is covered at 1 calendar quarter per course of treatment.	2				2				1	2	2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	015	0	1	01	01	H2697_015_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	016	0	1	01	01	H2697_016_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	017	0	1	01	01	H2697_017_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	018	0	1	01	01	H2697_018_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	019	0	1	01	01	H2697_019_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2697	020	0	1	01	01	H2697_020_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2697	022	0	1	01	01	H2697_022_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2704	015	0	1	01	01	H2704_015_0	4	2				2				1	55.00	55.00	55.00	2		2	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	2		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Occlusal guard is provided once every 5 years.	2				1	0.00	0.00	0.00	1	2
H2704	016	0	1	01	01	H2704_016_0	4	2				2				1	55.00	55.00	55.00	2		2	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided once per calendar year. Full-mouth X-rays are provided once every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	2		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Occlusal guard is provided once every 5 years.	2				1	0.00	0.00	0.00	1	2
H2715	003	0	1	01	01	H2715_003_0	8	2				2				1	40.00	40.00	40.00	2		2	2																																																																																																																																																																																																																																																																																		
H2715	006	1	1	01	01	H2715_006_1	9	2				1	30	30	30	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H2715	006	2	1	01	01	H2715_006_2	9	2				1	30	30	30	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H2737	001	0	1	04	01	H2737_001_0	6	2				2				3		50.00	450.00	2		1	2	1	2	775.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2737	801	0	1	04	01	H2737_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2737	802	0	1	04	01	H2737_802_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2737	803	0	1	04	01	H2737_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2752	003	0	1	01	01	H2752_003_0	6	2				1	20	20	20	2				2		1	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H2775	106	0	1	04	01	H2775_106_0	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2775	109	0	1	04	01	H2775_109_0	9	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2775	111	0	1	04	01	H2775_111_0	9	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2775	112	0	1	04	01	H2775_112_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	every 90 days to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 1 plan year	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 3 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	date of sevice to per lifetime	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H2775	113	0	1	04	01	H2775_113_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2775	115	0	1	04	01	H2775_115_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2775	116	0	1	04	01	H2775_116_0	8	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2802	001	0	1	02	01	H2802_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	007	0	1	02	01	H2802_007_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	008	0	1	02	01	H2802_008_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	010	0	1	02	01	H2802_010_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	012	0	1	02	01	H2802_012_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	024	0	1	02	01	H2802_024_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	025	0	1	02	01	H2802_025_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	028	0	1	02	01	H2802_028_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	029	0	1	02	01	H2802_029_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	030	0	1	02	01	H2802_030_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	031	0	1	02	01	H2802_031_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	032	0	1	02	01	H2802_032_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	033	0	1	02	01	H2802_033_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	034	0	1	02	01	H2802_034_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	035	0	1	02	01	H2802_035_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	041	0	1	02	01	H2802_041_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	044	0	1	02	01	H2802_044_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	048	0	1	02	01	H2802_048_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	049	0	1	02	01	H2802_049_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	050	0	1	02	01	H2802_050_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	052	0	1	02	01	H2802_052_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	053	0	1	02	01	H2802_053_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2802	054	0	1	02	01	H2802_054_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	055	0	1	02	01	H2802_055_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	056	0	1	02	01	H2802_056_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	058	0	1	02	01	H2802_058_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	059	0	1	02	01	H2802_059_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	060	0	1	02	01	H2802_060_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	061	0	1	02	01	H2802_061_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	062	0	1	02	01	H2802_062_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	063	0	1	02	01	H2802_063_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	064	0	1	02	01	H2802_064_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H2802	067	0	1	02	01	H2802_067_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	068	0	1	02	01	H2802_068_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	070	0	1	02	01	H2802_070_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	071	0	1	02	01	H2802_071_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	072	0	1	02	01	H2802_072_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	073	0	1	02	01	H2802_073_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	074	0	1	02	01	H2802_074_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	075	0	1	02	01	H2802_075_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	076	0	1	02	01	H2802_076_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H2802	077	0	1	02	01	H2802_077_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	078	0	1	02	01	H2802_078_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	079	0	1	02	01	H2802_079_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H2802	801	0	1	01	01	H2802_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	802	0	1	01	01	H2802_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	803	0	1	01	01	H2802_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	804	0	1	01	01	H2802_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	805	0	1	01	01	H2802_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	806	0	1	01	01	H2802_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	807	0	1	01	01	H2802_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	808	0	1	01	01	H2802_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	809	0	1	01	01	H2802_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	816	0	1	01	01	H2802_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	817	0	1	01	01	H2802_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	818	0	1	01	01	H2802_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	819	0	1	01	01	H2802_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	820	0	1	01	01	H2802_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	821	0	1	01	01	H2802_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	822	0	1	01	01	H2802_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	823	0	1	01	01	H2802_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2802	824	0	1	01	01	H2802_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H2815	001	0	1	20	08	H2815_001_0	2																																																																																																																																																																																																																																																																																																		
H2815	002	0	1	20	08	H2815_002_0	2																																																																																																																																																																																																																																																																																																		
H2816	013	0	1	09	04	H2816_013_0	8	2				2				1	20.00	20.00	20.00	2				2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00			2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00																																	2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00																		2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00		
H2816	019	0	1	09	04	H2816_019_0	8	2				2				1	20.00	20.00	20.00	2				2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00			2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00																																	2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00																		2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00		
H2816	037	0	1	09	04	H2816_037_0	8	2				2				1	20.00	20.00	20.00	2				2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00			2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00																																	2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00																		2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00		
H2816	038	0	1	09	04	H2816_038_0	7	2				2				1	20.00	20.00	20.00	2				2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00			2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00																																	2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00																		2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00		
H2816	040	0	1	09	04	H2816_040_0	8	2				2				1	20.00	20.00	20.00	2				2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	3		2				1	0.00	0.00	0.00			2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00			1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00			2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00			2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00																																																															2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00																		2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00		
H2819	001	0	1	01	01	H2819_001_0	8	2				1	20	20	20	2				2		2	1	2					2				2					2					2		2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2																																														2						2					2		2	2	2	3		2				2				1	1																2	2	1	1		2				2				1	1	2	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				2				1	1																															2	2	1	6	Benefits in this category are covered once per tooth every 5 calendar years.	2				2				1	1																																													
H2835	001	0	1	20	08	H2835_001_0	3																																																																																																																																																																																																																																																																																																		
H2835	002	0	1	20	08	H2835_002_0	3																																																																																																																																																																																																																																																																																																		
H2836	006	0	1	04	01	H2836_006_0	6	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2836	007	0	1	04	01	H2836_007_0	6	2				1	20	20	20	2				2		1	2	1	2	1200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H2845	001	0	1	04	01	H2845_001_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2845	002	0	1	04	01	H2845_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2845	003	0	1	04	01	H2845_003_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	005	0	1	04	01	H2845_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2845	006	0	1	04	01	H2845_006_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2845	008	0	1	04	01	H2845_008_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	009	0	1	04	01	H2845_009_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2845	010	0	1	04	01	H2845_010_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2853	801	0	1	01	01	H2853_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H2875	001	0	1	02	01	H2875_001_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H2875	002	0	1	02	01	H2875_002_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H2875	003	0	1	01	01	H2875_003_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H2875	004	0	1	01	01	H2875_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		6000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H2875	005	0	1	01	01	H2875_005_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		5000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H2875	006	0	1	02	01	H2875_006_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H2882	003	0	1	20	08	H2882_003_0	2																																																																																																																																																																																																																																																																																																		
H2882	004	0	1	20	08	H2882_004_0	2																																																																																																																																																																																																																																																																																																		
H2915	002	0	1	02	01	H2915_002_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2915	003	0	1	02	01	H2915_003_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2915	011	0	1	02	01	H2915_011_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2915	013	0	1	02	01	H2915_013_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H2915	018	0	1	02	01	H2915_018_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H2918	001	0	1	20	08	H2918_001_0	2																																																																																																																																																																																																																																																																																																		
H2918	002	0	1	20	08	H2918_002_0	2																																																																																																																																																																																																																																																																																																		
H2923	001	0	1	01	01	H2923_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2923	003	0	1	01	01	H2923_003_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2923	004	0	1	01	01	H2923_004_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2923	005	0	1	01	01	H2923_005_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2923	006	0	1	01	01	H2923_006_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H2923	009	0	1	01	01	H2923_009_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H2926	001	0	1	01	01	H2926_001_0	6	2				2				2				2		1	2																																																																																																																2						2					2		2	2	1	3		2				2				1	2																																																																																																																																							
H2936	001	0	1	20	08	H2936_001_0	3																																																																																																																																																																																																																																																																																																		
H2936	002	0	1	20	08	H2936_002_0	3																																																																																																																																																																																																																																																																																																		
H2937	001	0	1	20	08	H2937_001_0	2																																																																																																																																																																																																																																																																																																		
H2937	002	0	1	20	08	H2937_002_0	2																																																																																																																																																																																																																																																																																																		
H2941	001	0	1	20	08	H2941_001_0	3																																																																																																																																																																																																																																																																																																		
H2941	002	0	1	20	08	H2941_002_0	3																																																																																																																																																																																																																																																																																																		
H2942	001	0	1	01	01	H2942_001_0	5	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Intra oral bitewing X-ray when oral conditions indicate need: 2x per calendar year. X-ray of entire mouth, 1x per 5 years. Single tooth X-rays covered as needed.	2				2				2	2	2	2	1	6	Emergency oral evaluation problem-focused exams: covered once every calendar year. Diagnostic casts (study model): covered once every 36 months.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1					2					2		2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	Root Canal: 1x per tooth per lifetime. Retreatment Root Canal Therapy: 1x per tooth per lifetime at least 24 months after initial root canal. Apicoectomy: as needed. Retrograde filling: 1x per tooth	2				2				2	2	2	2	1	6	maintenance: 2x every 12 months following active periodontal therapy; not to be combined with regular cleanings. Scaling and Root Planning: 1x every 24 months per quadrant. Full mouth debridement: 1x	2				2				2	2	2	2	1	6	Dentures (complete or partial): one covered per arch within 7 years	2				2				2	2																															2	2	1	6	Fixed Bridges: covered once every 84 months.	2				2				2	2	2	2	1	6	Surgical Extractions: covered once per tooth	2				2				2	2																2	2	1	6	General Anesthesia, analgesia and IV sedation: allowed with covered oral surgery	2				2				2	2
H2942	002	0	1	01	01	H2942_002_0	5	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Intra oral bitewing X-ray when oral conditions indicate need: 2x per calendar year. X-ray of entire mouth, 1x per 5 years. Single tooth X-rays covered as needed.	2				2				2	2	2	2	1	6	Emergency oral evaluation problem-focused exams: covered once every calendar year. Diagnostic casts (study model): covered once every 36 months.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1					2					2		2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	Root Canal: 1x per tooth per lifetime. Retreatment Root Canal Therapy: 1x per tooth per lifetime at least 24 months after initial root canal. Apicoectomy: as needed. Retrograde filling: 1x per tooth	2				2				2	2	2	2	1	6	maintenance: 2x every 12 months following active periodontal therapy; not to be combined with regular cleanings. Scaling and Root Planning: 1x every 24 months per quadrant. Full mouth debridement: 1x	2				2				2	2	2	2	1	6	Dentures (complete or partial): one covered per arch within 7 years	2				2				2	2																															2	2	1	6	Fixed Bridges: covered once every 84 months.	2				2				2	2	2	2	1	6	Surgical Extractions: covered once per tooth	2				2				2	2																2	2	1	6	General Anesthesia, analgesia and IV sedation: allowed with covered oral surgery	2				2				2	2
H2942	003	0	1	01	01	H2942_003_0	5	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Intra oral bitewing X-ray when oral conditions indicate need: 2x per calendar year. X-ray of entire mouth, 1x per 5 years. Single tooth X-rays covered as needed.	2				2				2	2	2	2	1	6	Emergency oral evaluation problem-focused exams: covered once every calendar year. Diagnostic casts (study model): covered once every 36 months.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1					2					2		2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	Root Canal: 1x per tooth per lifetime. Retreatment Root Canal Therapy: 1x per tooth per lifetime at least 24 months after initial root canal. Apicoectomy: as needed. Retrograde filling: 1x per tooth	2				2				2	2	2	2	1	6	maintenance: 2x every 12 months following active periodontal therapy; not to be combined with regular cleanings. Scaling and Root Planning: 1x every 24 months per quadrant. Full mouth debridement: 1x	2				2				2	2	2	2	1	6	Dentures (complete or partial): one covered per arch within 7 years	2				2				2	2																															2	2	1	6	Fixed Bridges: covered once every 84 months.	2				2				2	2	2	2	1	6	Surgical Extractions: covered once per tooth	2				2				2	2																2	2	1	6	General Anesthesia, analgesia and IV sedation: allowed with covered oral surgery	2				2				2	2
H2960	009	0	1	01	01	H2960_009_0	3	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	INTRAORAL COMPLETE SERIES OR PANORAMIC RADIOGRAPHIC IMAGES: COVERED ONCE EVERY 3 CALENDAR YEARS	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1500.00	3		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years. 	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS. DENTURE REPAIR SERVICES, INCLUDIN	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	012	0	1	01	01	H2960_012_0	4	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H2960	018	0	1	01	01	H2960_018_0	4	2				2				1	15.00	15.00	15.00	2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1500.00	3		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS. DENTURE REPAIR SERVICES, INCLUDIN	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	019	0	1	01	01	H2960_019_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS	2				2				2	2																																														2	2	1	6	ALVEOLOPLASTY COVERED ONE PER SITE PER QUADRANT EVERY 5 CALENDAR YEARS. OROANTRAL FISTULA CLOSURE AND PRIMARY CLOSURE OF SINUS PERFORATION COVERED. INCISION AND DRAINAGE OF ABSCESS (INTRAORAL/EXTRAORA	1	0	0	0	2				2	2																														
H2960	023	0	1	01	01	H2960_023_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	ITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2					2		2	2	1	6	RESTORATIVE SERVICES- AMALGAMS OR RESIN COVERED ONCE PER SURFACE PER TOOTH EVERY 3 CALENDAR YEARS.INLAY, ONLAY, OR CROWNS: COVERED ONCE PER TOOTH PER 5 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	PERIODONTIC SERVICES- COVERED ONCE PER SITE PER QUADRANT EVERY 24 MONTHS. PERIODONTAL MAINTENANCE COVERED TWICE EVERY CALEANDAR YEAR.FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS.	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	024	0	1	01	01	H2960_024_0	4	2				1	17	17	17	2				2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2500.00	3		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARSOSSEOUS SURGERY COVERED ONCE PER SITE PER QUADRANT EVERY 2 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	PROSTHODONTIC SERVICES- IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS.	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	026	0	1	01	01	H2960_026_0	4	2				1	17	17	17	2				2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	BITEWINGS - SINGLE RADIOGRAPHIC IMAGES , 2 RADIOGRAPHIC IMAGES, 3 RADIOGRAPHIC IMAGES, AND 4 RADIOGRAPHIC IMAGES: COVERED ONCE EVERY CALENDAR YEAR.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	6	Amalgams or resin covered once per surface per tooth every 3 calendar years. Inlay, onlay or crowns covered once per tooth every 5 calendar years.	1	0	0	0	2				2	2	2	2	1	6	ENDODONTIC THERAPY- ONCE PER TOOTH PER LIFETIME	1	0	0	0	2				2	2	2	2	1	6	FULL MOUTH DEBRIDEMENT COVERED ONCE EVERY 3 CALENDAR YEARSOSSEOUS SURGERY COVERED ONCE PER SITE PER QUADRANT EVERY 2 CALENDAR YEARS	1	0	0	0	2				2	2	2	2	1	6	IMMEDIATE DENTURES COVERED ONCE PER ARCH PER 5 YEARS.REMOVABLE COMPLETE OR PARTIAL DENTURES IN RESIN AND METAL BASE, COVERED EVERY 5 YEARS.	1	0	0	0	2				2	2																																														2	2	1	6	ORAL SURGERY SERVICES- INCLUDES SIMPLE AND COMPLICATED EXTRACTIONS.	1	0	0	0	2				2	2																														
H2960	803	0	1	01	01	H2960_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H2962	001	0	1	01	01	H2962_001_0	13	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2																2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning), limited to 1 procedure per quadrant per year• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	021	0	1	01	01	H2962_021_0	16	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2	2	1				2				2				1	2																																														2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	023	0	1	01	01	H2962_023_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2	2	1				2				2				1	2																																														2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	025	0	1	01	01	H2962_025_0	16	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2	2	1				2				2				1	2																																														2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	026	0	1	01	01	H2962_026_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	028	0	1	01	01	H2962_028_0	13	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2																2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning), limited to 1 procedure per quadrant per year• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	029	0	1	01	01	H2962_029_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2	2	1				2				2				1	2																																														2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	033	0	1	01	01	H2962_033_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	035	0	1	01	01	H2962_035_0	11	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2	2	1				2				2				1	2																																														2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	036	0	1	01	01	H2962_036_0	11	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	7	6	• 1 full mouth debridement every 2 years• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2	2	1				2				2				1	2																																														2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	045	0	1	01	01	H2962_045_0	13	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2																2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning), limited to 1 procedure per quadrant per year• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	046	0	1	01	01	H2962_046_0	13	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2																2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning), limited to 1 procedure per quadrant per year• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	047	0	1	01	01	H2962_047_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2																2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning), limited to 1 procedure per quadrant per year• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	050	0	1	01	01	H2962_050_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	051	0	1	01	01	H2962_051_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2962	052	0	1	01	01	H2962_052_0	14	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	• 1 oral evaluation every 6 months}• 1 comprehensive oral exam every 3 years	2				2				2	2	2	2	2	6	$0 copay for the following:}• 2 dental x-ray every year}}Xrays may include:}•Intraoral, periapical first radiographic image}•Intraoral, periapical each additional radiographic image}•Bitewing, s	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2						2					2		2	2	4	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	6	6	• 4 periodontal scaling and root planing procedures (deep cleaning)• 2 periodontal maintenance procedures following active surgery per year	2				2				1	2																																																													2	2	2	3		2				2				1	2																2	1				2				2				1	2
H2992	001	0	1	20	08	H2992_001_0	2																																																																																																																																																																																																																																																																																																		
H2992	002	0	1	20	08	H2992_002_0	2																																																																																																																																																																																																																																																																																																		
H2992	003	0	1	20	08	H2992_003_0	2																																																																																																																																																																																																																																																																																																		
H2992	004	0	1	20	08	H2992_004_0	2																																																																																																																																																																																																																																																																																																		
H3038	002	0	1	01	01	H3038_002_0	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per y	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				2	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				2	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				2	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				2	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				2	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				2	2
H3038	004	1	1	01	01	H3038_004_1	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per y	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H3038	004	2	1	01	01	H3038_004_2	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per y	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H3038	004	3	1	01	01	H3038_004_3	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per y	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H3038	004	4	1	01	01	H3038_004_4	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per y	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H3041	001	0	1	01	01	H3041_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3041	003	0	1	01	01	H3041_003_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3048	001	0	1	01	01	H3048_001_0	10	2				1	20	20	20	2				2		1	2	1		2600.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2
H3048	002	0	1	01	01	H3048_002_0	11	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H3048	003	0	1	01	01	H3048_003_0	12	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H3060	001	0	1	20	08	H3060_001_0	2																																																																																																																																																																																																																																																																																																		
H3060	002	0	1	20	08	H3060_002_0	2																																																																																																																																																																																																																																																																																																		
H3071	002	0	1	01	01	H3071_002_0	9	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H3080	001	0	1	01	01	H3080_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3080	002	0	1	01	01	H3080_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3080	003	0	1	01	01	H3080_003_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3080	004	0	1	01	01	H3080_004_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3080	006	0	1	01	01	H3080_006_0	6	2				1	20	20	20	2				2		1	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3080	007	0	1	01	01	H3080_007_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3084	001	0	1	20	08	H3084_001_0	2																																																																																																																																																																																																																																																																																																		
H3084	002	0	1	20	08	H3084_002_0	2																																																																																																																																																																																																																																																																																																		
H3093	001	0	1	01	01	H3093_001_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H3093	002	0	1	01	01	H3093_002_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H3093	003	0	1	01	01	H3093_003_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H3093	004	0	1	01	01	H3093_004_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H3093	005	0	1	01	01	H3093_005_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H3113	005	0	1	01	01	H3113_005_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3113	009	0	1	02	01	H3113_009_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3113	010	0	1	02	01	H3113_010_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3113	014	0	1	02	01	H3113_014_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3113	016	0	1	02	01	H3113_016_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3124	001	0	1	04	01	H3124_001_0	19	2				2				1	45.00	45.00	45.00	2		2	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	3	3		2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H3124	002	0	1	04	01	H3124_002_0	19	2				2				1	40.00	40.00	40.00	2		2	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	3	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H3127	001	0	1	01	01	H3127_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3138	001	0	1	04	01	H3138_001_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	500.00	3		2				2					2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3													2	2	3													2	2	4	1				2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H3138	002	0	1	04	01	H3138_002_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3													2	2	3													2	2	4	1				2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H3138	003	0	1	04	01	H3138_003_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Bite-wing X-rays are provided one per year, Periapical X-rays 4 per year, Occlusal X-rays two per year and full-mouth X-rays are provided one every 5 years.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3													2	2	3													2	2	4	1				2				1	0.00	0.00	0.00	2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H3146	001	0	1	01	01	H3146_001_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	002	0	1	01	01	H3146_002_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	004	0	1	01	01	H3146_004_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3146	006	0	1	01	01	H3146_006_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	007	0	1	01	01	H3146_007_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	011	0	1	01	01	H3146_011_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	012	0	1	01	01	H3146_012_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	014	0	1	01	01	H3146_014_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	016	0	1	01	01	H3146_016_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	021	0	1	01	01	H3146_021_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	022	0	1	01	01	H3146_022_0	2	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3146	023	0	1	01	01	H3146_023_0	2	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3146	036	0	1	01	01	H3146_036_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	037	0	1	01	01	H3146_037_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3146	038	0	1	01	01	H3146_038_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3146	039	0	1	01	01	H3146_039_0	2	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	040	0	1	01	01	H3146_040_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	041	0	1	01	01	H3146_041_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	044	0	1	01	01	H3146_044_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3146	046	0	1	01	01	H3146_046_0	2	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	047	0	1	01	01	H3146_047_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3146	801	0	1	01	01	H3146_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3152	022	0	1	02	01	H3152_022_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3152	045	0	1	01	01	H3152_045_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3152	048	0	1	01	01	H3152_048_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3152	080	0	1	02	01	H3152_080_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3152	082	0	1	01	01	H3152_082_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3152	098	0	1	01	01	H3152_098_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3152	801	0	1	01	01	H3152_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3152	804	0	1	01	01	H3152_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3170	003	1	1	01	01	H3170_003_1	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1200.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3170	003	2	1	01	01	H3170_003_2	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1200.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3186	001	0	1	04	01	H3186_001_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3		2					2		2	2	1	6	Fillings - 1 per 24 monthsCrowns - 1 per 5 years	2				2				2	2	2	2	1	6	Root canal therapy - 1 per lifetime	2				2				2	2	2	2	1	1		2				2				2	2																																																													2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal, or cartilage graft) - 1 per lifetime	2				2				2	2																														
H3186	002	0	1	04	01	H3186_002_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	750.00	3		2					2		2	2	1	6	Fillings - 1 per 24 monthsCrowns - 1 per 5 years	2				2				2	2	2	2	1	6	Root canal therapy - 1 per lifetime	2				2				2	2	2	2	1	1		2				2				2	2																																																													2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal or cartilage graft) - 1 per lifetime	2				2				2	2																														
H3192	001	0	1	02	01	H3192_001_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	003	0	1	02	01	H3192_003_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	005	0	1	02	01	H3192_005_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	007	0	1	01	01	H3192_007_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3192	010	0	1	02	01	H3192_010_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	013	0	1	02	01	H3192_013_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	020	0	1	02	01	H3192_020_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	021	0	1	02	01	H3192_021_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	028	0	1	01	01	H3192_028_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3192	029	0	1	01	01	H3192_029_0	2	2				1	20	20	20	2				2		1	2	1		2250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3192	033	0	1	01	01	H3192_033_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3192	801	0	1	01	01	H3192_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3204	001	0	1	01	01	H3204_001_0	5	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3204	007	0	1	01	01	H3204_007_0	5	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3204	008	0	1	01	01	H3204_008_0	3	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3204	013	4	1	01	01	H3204_013_4	7	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3204	013	5	1	01	01	H3204_013_5	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3204	013	6	1	01	01	H3204_013_6	7	2				1	20	20	20	2				2		2	2	1		1800.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	4	3		2				2				2	2	2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	2	99	6	Dentures limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3204	017	0	1	01	01	H3204_017_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3204	801	0	1	01	01	H3204_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3204	802	0	1	01	01	H3204_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3204	803	0	1	01	01	H3204_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3204	808	0	1	02	01	H3204_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3204	809	0	1	02	01	H3204_809_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3204	810	0	1	02	01	H3204_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3219	001	0	1	04	01	H3219_001_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1400.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	002	0	1	04	01	H3219_002_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	003	0	1	04	01	H3219_003_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	004	0	1	04	01	H3219_004_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2100.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	005	0	1	04	01	H3219_005_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2100.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	008	0	1	04	01	H3219_008_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2050.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3219	012	0	1	04	01	H3219_012_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3219	014	0	1	04	01	H3219_014_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3219	015	0	1	04	01	H3219_015_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3219	016	0	1	04	01	H3219_016_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3219	801	0	1	04	01	H3219_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3239	001	0	1	01	01	H3239_001_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	002	0	1	01	01	H3239_002_0	2	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	005	0	1	01	01	H3239_005_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	007	0	1	01	01	H3239_007_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	010	0	1	01	01	H3239_010_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		1200.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	012	0	1	01	01	H3239_012_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	014	0	1	01	01	H3239_014_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	015	0	1	01	01	H3239_015_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	017	0	1	01	01	H3239_017_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	020	0	1	01	01	H3239_020_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	022	0	1	01	01	H3239_022_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3239	023	0	1	01	01	H3239_023_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	026	0	1	01	01	H3239_026_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	027	0	1	01	01	H3239_027_0	2	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	028	0	1	01	01	H3239_028_0	2	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3239	030	0	1	01	01	H3239_030_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3240	013	0	1	01	01	H3240_013_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3240	017	0	1	02	01	H3240_017_0	5	2				1	20	20	20	2				2		1	2	1		1200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3240	024	0	1	02	01	H3240_024_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3251	002	0	1	01	01	H3251_002_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H3251	029	0	1	01	01	H3251_029_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		4000.00	3		2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3251	804	0	1	01	01	H3251_804_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3256	004	1	1	04	01	H3256_004_1	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3256	004	2	1	04	01	H3256_004_2	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3256	005	1	1	04	01	H3256_005_1	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3256	005	2	1	04	01	H3256_005_2	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3256	006	1	1	04	01	H3256_006_1	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3256	006	2	1	04	01	H3256_006_2	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3259	001	0	1	01	01	H3259_001_0	11	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	2		3000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																														
H3259	002	0	1	01	01	H3259_002_0	12	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3259	003	0	1	01	01	H3259_003_0	11	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2																															1	2		3000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2	2	1				2				2				2	2																														
H3274	001	0	1	01	01	H3274_001_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3274	002	0	1	01	01	H3274_002_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3274	005	0	1	01	01	H3274_005_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3276	001	0	1	02	01	H3276_001_0	13	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	2		3000.00	3		2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				2				1	2																																														2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				2				1	2																2	1				2				2				1	2
H3284	001	0	1	20	08	H3284_001_0	2																																																																																																																																																																																																																																																																																																		
H3284	002	0	1	20	08	H3284_002_0	2																																																																																																																																																																																																																																																																																																		
H3288	001	0	1	04	01	H3288_001_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3288	002	0	1	04	01	H3288_002_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	003	0	1	04	01	H3288_003_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	004	0	1	04	01	H3288_004_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	005	0	1	04	01	H3288_005_0	4	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	006	0	1	04	01	H3288_006_0	3	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3288	007	0	1	04	01	H3288_007_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	008	0	1	04	01	H3288_008_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	009	0	1	04	01	H3288_009_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	011	0	1	04	01	H3288_011_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3288	016	0	1	04	01	H3288_016_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3288	017	0	1	04	01	H3288_017_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	018	0	1	04	01	H3288_018_0	3	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	019	0	1	04	01	H3288_019_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	020	0	1	04	01	H3288_020_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	021	0	1	04	01	H3288_021_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	027	0	1	04	01	H3288_027_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	034	0	1	04	01	H3288_034_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	042	0	1	04	01	H3288_042_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	046	0	1	04	01	H3288_046_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3288	047	0	1	04	01	H3288_047_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	048	0	1	04	01	H3288_048_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	051	0	1	04	01	H3288_051_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3288	053	0	1	04	01	H3288_053_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H3288	801	0	1	04	01	H3288_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3291	001	0	1	01	01	H3291_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3291	002	0	1	01	01	H3291_002_0	4	2				1	20	20	20	2				2		1	2	1		4200.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3291	003	0	1	01	01	H3291_003_0	3	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the notes for periodicity.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3305	007	0	1	02	01	H3305_007_0	8	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	015	0	1	02	01	H3305_015_0	17	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	020	0	1	02	01	H3305_020_0	8	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	022	0	1	02	01	H3305_022_0	16	2				2				1	35.00	35.00	35.00	2		2	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3305	033	0	1	01	01	H3305_033_0	9	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	1 to 3 times every 6 to 12 months depending on type of service. Some services have a lifetime limitation.	2				2				2	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	2	6	Every 12 to 36 months depending on type of service.	2				2				2	2	2	2	1	6	Every 6 to 12 months depending on type of service.	2				2				2	2	2	1				2				2				1	2	2						2					2		2	2	1	6	Every 12 to 60 months depending on type of service.	2				2				1	2	2	2	1	6	1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	Every 6 to 24 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 4 times every 12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 6 times every 2 to 12 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	24 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 3 times every 6 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2																2	2	1	6	1 to 4 times every 1 day to 12 months depending on type of service.	2				2				1	2
H3305	034	0	1	01	01	H3305_034_0	9	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	1 to 3 times every 6 to 12 months depending on type of service. Some services have a lifetime limitation.	2				2				2	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	1	6	1 to 3 times every 1 week to 36 months depending on type of service. Some services have a lifetime limitation.	2				2				1	2	2	2	2	6	Every 12 to 36 months depending on type of service.	2				2				2	2	2	2	1	6	Every 6 to 12 months depending on type of service.	2				2				2	2	2	1				2				2				1	2	2						2					2		2	2	1	6	Every 12 to 60 months depending on type of service.	2				2				1	2	2	2	1	6	1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	Every 6 to 24 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 4 times every 12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 6 times every 2 to 12 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	12 to 96 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	24 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2	2	2	1	6	1 to 3 times every 6 to 60 months depending on type of service. Some services 1 per tooth in a lifetime.	2				2				1	2																2	2	1	6	1 to 4 times every 1 day to 12 months depending on type of service.	2				2				1	2
H3305	801	0	1	02	01	H3305_801_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3305	803	0	1	02	01	H3305_803_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3305	804	0	1	02	01	H3305_804_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3312	002	0	1	01	01	H3312_002_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	018	0	1	02	01	H3312_018_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	048	0	1	01	01	H3312_048_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	062	0	1	01	01	H3312_062_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	064	0	1	01	01	H3312_064_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	065	0	1	02	01	H3312_065_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	069	0	1	01	01	H3312_069_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	070	0	1	01	01	H3312_070_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	073	0	1	01	01	H3312_073_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	074	0	1	01	01	H3312_074_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	081	0	1	01	01	H3312_081_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	082	0	1	01	01	H3312_082_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	087	0	1	01	01	H3312_087_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	089	0	1	01	01	H3312_089_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	090	0	1	01	01	H3312_090_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2
H3312	091	0	1	01	01	H3312_091_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3312	097	0	1	01	01	H3312_097_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3312	801	0	1	01	01	H3312_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3312	804	0	1	01	01	H3312_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3321	001	0	1	20	08	H3321_001_0	2																																																																																																																																																																																																																																																																																																		
H3321	003	0	1	20	08	H3321_003_0	2																																																																																																																																																																																																																																																																																																		
H3322	001	0	1	20	08	H3322_001_0	2																																																																																																																																																																																																																																																																																																		
H3322	002	0	1	20	08	H3322_002_0	2																																																																																																																																																																																																																																																																																																		
H3329	001	0	1	20	08	H3329_001_0	2																																																																																																																																																																																																																																																																																																		
H3329	002	0	1	20	08	H3329_002_0	2																																																																																																																																																																																																																																																																																																		
H3330	021	2	1	01	01	H3330_021_2	6	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				3		0.00	150.00	1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	021	3	1	01	01	H3330_021_3	6	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				3		0.00	150.00	1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	021	5	1	01	01	H3330_021_5	6	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				3		0.00	150.00	1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	038	0	1	01	01	H3330_038_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				3		0.00	125.00	1	2	2	2	1	6	1 per tooth per lifetime	2				3		0.00	20.00	1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				3		0.00	150.00	1	2																															2	2	1	6	1 every 60 months	2				3		0.00	150.00	1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				3		0.00	50.00	1	2																2	1				2				2				1	2
H3330	048	0	1	02	01	H3330_048_0	7	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	1					2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	1	50	50	50	2				1	2	2	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 months	1	50	50	50	2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	1	50	50	50	2				1	2																															2	2	1	6	1 every 60 months	1	50	50	50	2				1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H3330	814	0	1	01	01	H3330_814_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3330	815	0	1	01	01	H3330_815_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3330	820	0	1	02	01	H3330_820_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3330	821	0	1	02	01	H3330_821_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3331	001	0	1	20	08	H3331_001_0	3																																																																																																																																																																																																																																																																																																		
H3331	002	0	1	20	08	H3331_002_0	3																																																																																																																																																																																																																																																																																																		
H3335	015	0	1	04	01	H3335_015_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	018	0	1	04	01	H3335_018_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	038	0	1	04	01	H3335_038_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	043	0	1	04	01	H3335_043_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	044	0	1	04	01	H3335_044_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	053	0	1	04	01	H3335_053_0	8	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	055	0	1	04	01	H3335_055_0	8	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3335	060	0	1	04	01	H3335_060_0	8	2				2				1	15.00	15.00	15.00	2		2	2																																																																																																																																																																																																																																																																																		
H3335	061	0	1	04	01	H3335_061_0	7	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H3335	062	0	1	04	01	H3335_062_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H3335	801	0	1	04	01	H3335_801_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	811	0	1	04	01	H3335_811_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	813	0	1	04	01	H3335_813_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	819	0	1	04	01	H3335_819_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	820	0	1	04	01	H3335_820_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	822	0	1	04	01	H3335_822_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	824	0	1	04	01	H3335_824_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3335	825	0	1	04	01	H3335_825_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3344	013	0	1	04	01	H3344_013_0	7	2				2				3		40.00	550.00	2		1	2	1	2	1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3344	801	0	1	04	01	H3344_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3344	804	0	1	04	01	H3344_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3344	805	0	1	04	01	H3344_805_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3347	002	0	1	02	01	H3347_002_0	8	2				1	20	20	20	2				2		2	2	2					2				2					1	111101	0.00	0.00	0.00	2		2	2	1	6	Oral Exams: $0 copayment 1 every month or 6 or 12 months	2								2	2	2	2	1	6	X Rays: $0 copay for select codes. $0 copay for  1 every 6,  12 or 36 months. Select codes covered 2 every  6 or 12 months.	2								2	2	2	2	1	6	Other Diagnostic Services: $0 copay for select codes.	2								2	2	2	2	1	4		2								2	2																2	2	1	6	Other Preventive Services: $0 copay for select codes.	2								2	2	2						2					2		2	2	1	6	Coverage is limited to select codes. Restorative:  $0 copay /1 every 12, 24, or 60 Mo Select codes $0 copay /2 every 12 Mo Select codes are covered at $0 copay. $0 copay 1 per lifetime	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic ServicesSelect Codes Only at $0 copayment /1 per lifetime. Select codes are covered at $0 copay	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodontics Services: Select Codes Only at $0 copayment /1 every 6, 12, 24, 36, or 60 months. Select codes only at $0 Copayment/ 1 per lifetime. Select codes are covered at $0 copay.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Select Codes Only at $0 copayment /1 every 12 months. $0 copayment  / 2 every 12 months. $0 copayment 4 every 12 months. $0 copayment 1 every 24 months. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Maxillofacial Prosthetics services Select Codes Only at $0 copayment  1 every 6 or 12 months / 2 every 12 months. / 6 every 2 months.Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Select Codes only at $0 copayment every 12 or 24 months. $0 copayment for 1 every 8 years. $0 copayment for 1 per lifetime.Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Prosthodontics, fixed services Select Codes Only at $0 copayment /1 every 60 months. $0 copayment  / 1 every 24 months. Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Select Codes Only at $0 copay / 1 every 6 or 12 months/ 1 every 24 months. 2 every  60 months. $0 copay  / 1 every lifetime. $0 copay / 2 every lifetime. $0 copay / 3 every lifetime. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Adjunctive General ServicesSelect Codes Only at $0 copayment /1 every 6 or 12 months. $0 copayment  / 2 every 12 months. Select codes are covered at $0 copayment. $0 copayment/ 1 every 7 days	2				1	0.00	0.00	0.00	2	2
H3347	003	0	1	02	01	H3347_003_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3347	007	0	1	02	01	H3347_007_0	9	2				1	20	20	20	2				2		2	2	2					2				2					1	111101	0.00	0.00	0.00	2		2	2	1	6	Oral Exams: $0 copayment 1 every month or 6 monthsSelect codes covered  1 every 12 months.	2								2	2	2	2	1	6	X Rays: $0 copay for select codes. $0 copay for  1 every 6,  12 or 36 months. Select codes covered 2 every  6 or 12 months.	2								2	2	2	2	1	6	Other Diagnostic Services: $0 copay for select codes.	2								2	2	2	2	1	4		2								2	2																2	2	1	6	Other Preventive Services: $0 copay for select codes.	2								2	2	2						2					2		2	2	1	6	Coverage is limited to select codes. Restorative:  $0 copay /1 every 12, 24, or 60 Mo Select codes $0 copay /2 every 12 Mo Select codes are covered at $0 copay. $0 copay 1 per lifetime	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic ServicesSelect Codes Only at $0 copayment /1 per lifetime. Select codes are covered at $0 copay	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodontics Services: Select Codes Only at $0 copayment /1 every 6, 12, 24, 36, or 60 months. Select codes only at $0 Copayment/ 1 per lifetime. Select codes are covered at $0 copay.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Select Codes Only at $0 copayment /1 every 12 months. $0 copayment  / 2 every 12 months. $0 copayment 4 every 12 months. $0 copayment 1 every 24 months. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Maxillofacial Prosthetics services Select Codes Only at $0 copayment  1 every 6 or 12 months. / 2 every 12 months. / 6 every 2 months.Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Select Codes only at $0 copayment every 12 or 24 months. $0 copayment for 1 every 8 years. $0 copayment for 1 per lifetime.Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Prosthodontics, fixed services Select Codes Only at $0 copayment /1 every 60 months. $0 copayment  / 1 every 24 months. Select codes are covered at $0 copayment	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Select Codes Only at $0 copay / 1 every 6 or 12 months/ 1 every 24 months. 2 every  60 months. $0 copay  / 1 every lifetime. $0 copay / 2 every lifetime. $0 copay / 3 every lifetime. Select codes are covered at $0 copayment.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Adjunctive General ServicesSelect Codes Only at $0 copayment /1 every 6 or 12 months. $0 copayment  / 2 every 12 months. Select codes are covered at $0 copayment. $0 copayment/ 1 every 7 days	2				1	0.00	0.00	0.00	2	2
H3347	009	0	1	02	01	H3347_009_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X Rays: $0 copay for 1 every 12 or 36 months.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	1	6	Select Codes Only at $0 copayment /1 every 6 months, 24 months, or 60 months. $50 copayment /1 every 60 months, or$150 copayment /1 every 60 months.	2				3		0.00	150.00	2	2	2	2	1	6	Endodontic Services: Select Codes Only at $0 copayment /1 per lifetime or $40 copayment /1 per lifetime.	2				3		0.00	40.00	2	2	2	2	1	6	Periodontic Services: Select Codes Only at $0 copayment /1 every 36 months. $40 copayment/1 every 36  months .$40 copayment/1 every 60 months.  Select codes only at $150 copayment/1 every 60 months.	2				3		0.00	150.00	2	2	2	2	1	6	Prosthodontics Services: Selected Codes Only at $0 copayment , $0 copayment / 1 every 12 months, or $150 copayment / 1 every 60 months.	2				3		0.00	150.00	2	2																															2	2	1	6	Prosthodontics fixed Services: Selected Codes Only at $0 copayment. $100 copayment / 1 every 60 months. $150 copayment / 1 every 60 months.	2				3		0.00	150.00	2	2	2	2	1	6	Oral and Maxillofacial Surgery Services: Select Codes Only at $0 copayment / 1 every 12 months. $0 copayment / 1 every lifetime. Select codes only at $100 copayment. $100 copayment /1 per lifetime.	2				3		0.00	100.00	2	2																2	2	1	6	Adjunctive General Services Selected Codes Only $0 copayment.	2				1	0.00	0.00	0.00	2	2
H3347	016	0	1	02	01	H3347_016_0	8	2				1	20	20	20	2				2		2	2	2					2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	6	Coverage is limited to select codes. X Rays: $0 copay for 1 every 12 or 36 months. $0 copay for select codes.	2								2	2																2	2	1	4		2								2	2	2	2	1	4		2								2	2																1	2		2500.00	3		2					2		2	2	1	6	Restorative Services Select Codes Only at $0copayment /1 every 6 months, 24 months, or 60months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services Select Codes Only at $0copayment /1 per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodontic Services Select Codes Only at $0copayment /1 every 36 months. $0copayment 1/ every 60 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Prosthodontics Services Selected Codes Only at $0 copayment. $0 copayment/ 1 every 12 months, $0 copayment / 1 every 60 months.	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	Prosthodontics fixed Services: Selected Codes Only at $0 copayment. $0 copayment / 1 every 60 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Oral and Maxillofacial Surgery Services: Select Codes Only at $0 copayment. $0 copayment / 1 every 12 months or $0 copayment/ 1 per lifetime.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	Adjunctive General Services Selected Codes Only $0 copayment.	2				1	0.00	0.00	0.00	2	2
H3347	018	0	1	02	01	H3347_018_0	8	2				1	20	20	20	2				2		2	2	1		1500.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2
H3351	001	0	1	02	01	H3351_001_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3351	002	0	1	02	01	H3351_002_0	7	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3351	006	0	1	02	01	H3351_006_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	007	0	1	02	01	H3351_007_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		500.00	3		2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				2				2	2																															4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H3351	012	0	1	02	01	H3351_012_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3351	017	0	1	01	01	H3351_017_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3351	019	0	1	02	01	H3351_019_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3351	020	0	1	01	01	H3351_020_0	6	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3351	022	0	1	01	01	H3351_022_0	7	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H3351	023	0	1	01	01	H3351_023_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	4	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H3351	801	0	1	02	01	H3351_801_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3351	802	0	1	02	01	H3351_802_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3351	803	0	1	02	01	H3351_803_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3351	804	0	1	02	01	H3351_804_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3351	805	0	1	02	01	H3351_805_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3351	806	0	1	02	01	H3351_806_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3359	001	0	1	01	01	H3359_001_0	8	2				2				2				2		1	2	1		1250.00	3		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	1				2				2				1	2	1	1					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	019	0	1	01	01	H3359_019_0	9	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	1				2				2				1	2	1	2		1500.00	3		2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	021	0	1	01	01	H3359_021_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2						2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	034	0	1	01	01	H3359_034_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	Limits vary by procedure	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2						2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	038	0	1	01	01	H3359_038_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				2	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2						2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2
H3359	808	0	1	01	01	H3359_808_0	1	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H3359	809	0	1	01	01	H3359_809_0	1	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H3362	016	0	1	01	01	H3362_016_0	6	2				2				3		10.00	550.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	020	0	1	01	01	H3362_020_0	6	2				2				3		0.00	550.00	2		1	2																																																																																																																																																																																																																																																																																		
H3362	040	0	1	01	01	H3362_040_0	7	2				2				3		20.00	550.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	042	0	1	01	01	H3362_042_0	7	2				2				3		40.00	743.00	2		1	2	1		1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	043	0	1	01	01	H3362_043_0	7	2				2				3		25.00	550.00	2		1	2	1		1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	044	0	1	01	01	H3362_044_0	7	2				2				3		35.00	600.00	2		1	2	1		1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bitewing x-rays limited to twice in any calendar year. Full mouth x-rays limited to once every 36 months.	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																														2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3362	801	0	1	01	01	H3362_801_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3362	807	0	1	02	01	H3362_807_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3362	819	0	1	02	01	H3362_819_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3362	820	0	1	01	01	H3362_820_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3379	001	0	1	02	01	H3379_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3379	039	0	1	02	01	H3379_039_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3379	040	0	1	02	01	H3379_040_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3379	043	0	1	02	01	H3379_043_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3379	052	0	1	02	01	H3379_052_0	4	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3379	053	0	1	02	01	H3379_053_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3379	054	0	1	02	01	H3379_054_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3379	056	0	1	02	01	H3379_056_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3379	059	0	1	02	01	H3379_059_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3379	060	0	1	02	01	H3379_060_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3379	802	0	1	01	01	H3379_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3379	803	0	1	01	01	H3379_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3379	804	0	1	01	01	H3379_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3384	013	0	1	01	01	H3384_013_0	5	2				2				1	26.00	26.00	26.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	3		0	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered. Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime.	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	019	0	1	01	01	H3384_019_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	3		0	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered. Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	022	0	1	01	01	H3384_022_0	4	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of a routine cleaning and periodontal cleaning is covered at 100% (no member cost sharing), 2 per calendar year.	2				2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered. Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H3384	069	1	1	01	01	H3384_069_1	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	069	2	1	01	01	H3384_069_2	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	069	3	1	01	01	H3384_069_3	6	2				2				1	55.00	55.00	55.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	070	1	1	01	01	H3384_070_1	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	070	2	1	01	01	H3384_070_2	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	070	3	1	01	01	H3384_070_3	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered.  Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	071	0	1	01	01	H3384_071_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3384	805	0	1	01	01	H3384_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3384	806	0	1	01	01	H3384_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3384	811	0	1	02	01	H3384_811_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3384	812	0	1	02	01	H3384_812_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3384	813	0	1	01	01	H3384_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3387	013	0	1	02	01	H3387_013_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	1	1	02	01	H3387_014_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	014	2	1	02	01	H3387_014_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	015	1	1	02	01	H3387_015_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	015	2	1	02	01	H3387_015_2	6	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3387	017	0	1	02	01	H3387_017_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 12 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity for each service in this category is 2 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 4 every 12 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 36 months to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 48 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2
H3388	001	0	1	01	01	H3388_001_0	2	2				2				1	25.00	25.00	25.00	2		2	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3388	002	0	1	01	01	H3388_002_0	4	2				2				1	25.00	25.00	25.00	2		2	1	1		1650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	2	2	1				2				2				2	2
H3388	014	0	1	01	01	H3388_014_0	4	2				2				1	35.00	35.00	35.00	2		2	1	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	1	2	1				2				2				2	1	2	1				2				2				2	2	2	1				2				2				2	2
H3388	020	0	1	01	01	H3388_020_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1		900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3388	801	0	1	01	01	H3388_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3388	803	0	1	01	01	H3388_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3388	804	0	1	01	01	H3388_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3404	003	1	1	04	01	H3404_003_1	9	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	See detailed note below.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed note below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures covered 1 per arch every 60 months.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	Surgical procedures covered once every 60 monthsAlveoloplasty covered once every 60 monthsFrenulectomy, frenectomy or frenotomy (separate procedures) covered once every 60 months	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed notes below.	2				1	0.00	0.00	0.00	2	2
H3404	003	2	1	04	01	H3404_003_2	9	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	See detailed note below.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed note below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Complete and partial dentures covered 1 per arch every 60 months.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	Surgical procedures covered once every 60 monthsAlveoloplasty covered once every 60 monthsFrenulectomy, frenectomy or frenotomy (separate procedures) covered once every 60 months	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed notes below.	2				1	0.00	0.00	0.00	2	2
H3404	004	0	1	04	01	H3404_004_0	8	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3404	801	0	1	04	01	H3404_801_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3404	810	0	1	04	01	H3404_810_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3404	811	0	1	04	01	H3404_811_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3407	001	0	1	01	01	H3407_001_0	8	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	2	1	6	restorative fillings one per surface per tooth every 2 years.   Restorative Inlay/Onlay one per tooth every 5 years. Restorative crowns is one per tooth every 5 years. Restorative repair is unlimited.	2				2				1	2	2	2	1	6	Endodontics one per tooth per lifetime.	2				2				2	2	2	2	1	6	Periodontal root planning and scaling one per quadrant every 2 years. Periodontal surgical services one per quadrant every 3 years.	2				2				1	2	2	2	1	6	Prosthodontics (dentures) one set every 5 years. Denture adjustments/repair one per arch every year. Denture reline one per arch every 2 years.	2				2				1	2																2	2	1	6	Implants 1 per tooth every 5 years.	2				2				1	2	2	2	1	6	Fixed partial dentures (bridges) one per tooth every 5 years.	2				2				1	2	2	2	1	6	Surgical extractions one per site/quadrant per lifetime.	2				2				1	2																2	2	1	6	Occusal guards one every 3 years. Tele-dentistry 2 every year.	2				2				1	2
H3407	002	0	1	01	01	H3407_002_0	8	2				2				1	25.00	25.00	25.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Restorative fillings one per surface per tooth every 2 years. Restorative inlay/onlay 1 per tooth every 5 years. Restorative crowns one per tooth every 5 years. Restorative repair unlimited.	2				2				2	2	2	2	1	6	Endodontics 1 per tooth per lifetime	2				2				1	2	2	2	1	6	Periodontal Root Planning and Scaling, one per site/quadrant every 2 years. Periodontal Surgical Services, one per site/quadrant every 5 years.	2				2				2	2	2	2	1	6	Prosthodontics (Dentures) one set every 5 years. Denture adjustments/repair 1 per arch every year. Denture reline, one per arch every 2 years.	2				2				2	2																															2	2	1	6	Fixed partial denture (bridges) one per tooth every five years.	2				2				2	2	2	2	1	6	Surgical extractions 1 per site/quadrant per lifetime.	2				2				2	2																2	2	1	6	Occusal guards 1 every 3 years. Teledentistry 2 every year.	2				2				2	2
H3407	003	0	1	01	01	H3407_003_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3418	001	0	1	04	01	H3418_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3418	002	0	1	04	01	H3418_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3418	004	0	1	04	01	H3418_004_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3418	008	0	1	04	01	H3418_008_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3419	001	0	1	01	01	H3419_001_0	6	2				1	20	20	20	2				2		1	2	1		2300.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3419	003	0	1	02	01	H3419_003_0	7	2				1	20	20	20	2				2		1	2	1		2600.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3419	004	0	1	02	01	H3419_004_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3419	005	0	1	01	01	H3419_005_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H3419	006	0	1	01	01	H3419_006_0	4	2				1	20	20	20	2				2		1	2	1		2100.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H3419	007	0	1	01	01	H3419_007_0	4	2				1	20	20	20	2				2		1	2	1		2100.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H3430	001	0	1	20	08	H3430_001_0	2																																																																																																																																																																																																																																																																																																		
H3430	002	0	1	20	08	H3430_002_0	2																																																																																																																																																																																																																																																																																																		
H3443	001	0	1	01	01	H3443_001_0	10	2				2				2				2		1	2	2					2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		2000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	002	0	1	01	01	H3443_002_0	10	2				2				2				2		1	2	2					2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		2000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	003	0	1	01	01	H3443_003_0	10	2				2				2				2		1	2	2					2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																2						2					2		2	1				2				3		20.00	400.00	1	2	2	1				2				3		25.00	350.00	1	2	2	1				2				3		15.00	550.00	1	2	2	1				2				3		20.00	570.00	1	2																															2	1				2				3		40.00	400.00	1	2	2	1				2				3		25.00	250.00	1	2																														
H3443	005	0	1	01	01	H3443_005_0	11	2				2				2				2		1	2	2					2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																																																																																																																																																																																		
H3443	006	0	1	01	01	H3443_006_0	10	2				1	20	20	20	2				2		1	2	1		3800.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	007	0	1	01	01	H3443_007_0	7	2				2				2				2		1	2	1		2400.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3443	801	0	1	01	01	H3443_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3443	802	0	1	01	01	H3443_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3443	803	0	1	01	01	H3443_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3443	804	0	1	01	01	H3443_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3447	013	0	1	02	01	H3447_013_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																		
H3447	018	0	1	01	01	H3447_018_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	024	0	1	02	01	H3447_024_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	025	0	1	02	01	H3447_025_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																		
H3447	033	0	1	02	01	H3447_033_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1800.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	037	0	1	02	01	H3447_037_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	038	1	1	02	01	H3447_038_1	5	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	038	2	1	02	01	H3447_038_2	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	039	0	1	02	01	H3447_039_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	1	1	02	01	H3447_042_1	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	2	1	02	01	H3447_042_2	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	3	1	02	01	H3447_042_3	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	042	4	1	02	01	H3447_042_4	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	049	0	1	02	01	H3447_049_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	050	0	1	02	01	H3447_050_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	051	0	1	02	01	H3447_051_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	052	0	1	02	01	H3447_052_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3447	053	0	1	01	01	H3447_053_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	056	0	1	02	01	H3447_056_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H3447	804	0	1	01	01	H3447_804_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	805	0	1	01	01	H3447_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	806	0	2	01	01	H3447_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	807	0	2	01	01	H3447_807_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	809	0	1	01	01	H3447_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	811	0	1	01	01	H3447_811_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	812	0	1	01	01	H3447_812_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	813	0	2	01	01	H3447_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	814	0	2	01	01	H3447_814_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	816	0	1	01	01	H3447_816_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	818	0	1	01	01	H3447_818_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	819	0	1	01	01	H3447_819_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	820	0	2	01	01	H3447_820_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	821	0	2	01	01	H3447_821_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	823	0	1	01	01	H3447_823_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	825	0	2	01	01	H3447_825_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	826	0	2	01	01	H3447_826_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3447	827	0	2	01	01	H3447_827_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3449	012	0	1	02	01	H3449_012_0	8	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	023	1	1	02	01	H3449_023_1	9	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	023	2	1	02	01	H3449_023_2	9	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	023	4	1	02	01	H3449_023_4	9	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	023	5	1	02	01	H3449_023_5	9	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	024	1	1	02	01	H3449_024_1	9	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	024	2	1	02	01	H3449_024_2	9	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	024	3	1	02	01	H3449_024_3	9	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H3449	026	0	1	01	01	H3449_026_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2						2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	027	1	1	01	01	H3449_027_1	9	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2						2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	027	2	1	01	01	H3449_027_2	10	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															2						2					2																																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																											2	2	1	6	Palliative treatment/minor procedure covered once every calendar year.  Teledentistry covered twice every calendar year.	2				1	0.00	0.00	0.00	2	2
H3449	805	0	1	01	01	H3449_805_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3449	814	0	1	01	01	H3449_814_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3449	815	0	1	01	01	H3449_815_0	6	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3467	001	0	1	02	01	H3467_001_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																																																																																																																																																																																		
H3467	002	0	1	02	01	H3467_002_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																																																																																																																																																																																		
H3467	005	0	1	02	01	H3467_005_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																																																																																																																																																																																		
H3473	001	0	1	20	08	H3473_001_0	2																																																																																																																																																																																																																																																																																																		
H3473	002	0	1	20	08	H3473_002_0	2																																																																																																																																																																																																																																																																																																		
H3493	001	0	1	20	08	H3493_001_0	2																																																																																																																																																																																																																																																																																																		
H3493	002	0	1	20	08	H3493_002_0	2																																																																																																																																																																																																																																																																																																		
H3499	002	0	1	02	01	H3499_002_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H3499	008	0	1	02	01	H3499_008_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H3517	001	0	1	20	08	H3517_001_0	2																																																																																																																																																																																																																																																																																																		
H3517	002	0	1	20	08	H3517_002_0	2																																																																																																																																																																																																																																																																																																		
H3522	001	0	1	20	08	H3522_001_0	2																																																																																																																																																																																																																																																																																																		
H3522	002	0	1	20	08	H3522_002_0	2																																																																																																																																																																																																																																																																																																		
H3528	003	0	1	02	01	H3528_003_0	10	2				2				1	10.00	10.00	10.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	2		3000.00	3		2					1	100.00	2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	2	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 months per quadrant	1	50	50	50	2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	1	50	50	50	2				1	2																																														2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																2	1				2				2				1	2
H3528	010	0	1	02	01	H3528_010_0	13	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	2		2000.00	3		2					1	100.00	2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	2	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 months per quadrant	1	50	50	50	2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	1	50	50	50	2				1	2																																														2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																2	1				2				2				1	2
H3528	011	1	1	02	01	H3528_011_1	13	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		4	2	1	4		2				2				2	2	4	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	4	1				2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2																																																																																																																																																																			
H3528	011	2	1	02	01	H3528_011_2	13	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		4	2	1	4		2				2				2	2	4	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	4	1				2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2	4	2	1	4		2				2				2	2																																																																																																																																																																			
H3528	014	0	1	02	01	H3528_014_0	13	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	1	2		2000.00	3		2					1	100.00	2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	2	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 months per quadrant	1	50	50	50	2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	1	50	50	50	2				1	2																																														2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																2	1				2				2				1	2
H3528	015	0	1	02	01	H3528_015_0	13	2				2				1	35.00	35.00	35.00	2		2	2																																																																																																																																																																																																																																																																																		
H3528	016	0	1	02	01	H3528_016_0	14	2				2				1	30.00	30.00	30.00	2		2	2																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2	3													2	2
H3533	002	0	1	01	01	H3533_002_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	comp dentures, part dentures 1 every 8 years, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																2	2	1	6	restoration implant 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H3533	027	0	1	01	01	H3533_027_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H3533	033	0	1	01	01	H3533_033_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H3533	034	1	1	01	01	H3533_034_1	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	comp dentures, part dentures 1 every 8 years, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																2	2	1	6	restoration implant 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H3533	034	2	1	01	01	H3533_034_2	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	comp dentures, part dentures 1 every 8 years, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																2	2	1	6	restoration implant 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H3533	035	0	1	01	01	H3533_035_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H3533	802	0	1	01	01	H3533_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H3533	803	0	1	01	01	H3533_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H3533	805	0	1	01	01	H3533_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H3533	806	0	1	01	01	H3533_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H3536	801	0	1	01	01	H3536_801_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3536	802	0	1	01	01	H3536_802_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3536	803	0	2	01	01	H3536_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3536	804	0	2	01	01	H3536_804_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3536	806	0	1	01	01	H3536_806_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3536	808	0	2	01	01	H3536_808_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3551	001	0	1	01	01	H3551_001_0	4	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3551	002	0	1	01	01	H3551_002_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3551	003	0	1	02	01	H3551_003_0	4	2				1	20	20	20	2				2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3551	004	0	1	01	01	H3551_004_0	4	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3557	801	0	1	04	01	H3557_801_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3557	802	0	1	04	01	H3557_802_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3557	803	0	1	04	01	H3557_803_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3561	007	0	1	01	01	H3561_007_0	8	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3561	008	0	1	01	01	H3561_008_0	8	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every year to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2																																													
H3561	009	0	1	01	01	H3561_009_0	8	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every year to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2																																													
H3563	001	0	1	20	08	H3563_001_0	2																																																																																																																																																																																																																																																																																																		
H3563	002	0	1	20	08	H3563_002_0	2																																																																																																																																																																																																																																																																																																		
H3597	001	0	1	02	01	H3597_001_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3597	011	0	1	02	01	H3597_011_0	2	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3597	012	0	1	02	01	H3597_012_0	2	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3597	017	0	1	02	01	H3597_017_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3597	018	0	1	02	01	H3597_018_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3597	801	0	1	01	01	H3597_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3597	802	0	1	01	01	H3597_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3613	001	0	1	20	08	H3613_001_0	2																																																																																																																																																																																																																																																																																																		
H3613	002	0	1	20	08	H3613_002_0	2																																																																																																																																																																																																																																																																																																		
H3653	004	0	1	02	01	H3653_004_0	12	2				1	0	0	0	2				2		1	2	1		4500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2				2				2	2	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	1	0	0	0	2				2	2	2	2	2	6	Scaling and root planning subject to utilization review and must contain 4 teeth with 4+MM pockets, covered every 3 years. Maintenance is covered 1 per benefit plan year.	2				2				2	2	2	2	1	6	Denture replacement limited to every 5 years.	2				2				2	2																															2	2	1	6	Denture replacement limited to every 5 years.	1	0	0	0	2				2	2	2	1				2				2				2	2																2	2	1	6	Teledentistry visit (real-time synchronous encounter) with Dental provider covered once per benefit plan year.	2				2				2	2
H3653	015	0	1	02	01	H3653_015_0	15	2				1	0	0	0	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2				2				2	2	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2				2				2	2	2	2	2	6	Periodontics Maintenance only twice per year and Root planning must contain 4 teeth with 4+MM pockets, covered every 3 years	2				2				2	2	2	2	1	6	Denture replacement limited to every 5 years.	2				2				2	2																															2	2	1	6	Denture replacement limited to every 5 years.	1	0	0	0	2				2	2	2	1				2				2				2	2																2	2	1	6	Teledentistry visit (real-time synchronous encounter) with Dental provider covered once per benefit plan year.	2				2				2	2
H3653	022	0	1	02	01	H3653_022_0	13	2				1	0	0	0	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Amalgam and Resin based composites are limited to one procedure per tooth every 3 years.	2				2				2	2	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Denture replacement limited to every 5 years.	2				2				2	2																															2	2	1	6	Denture replacement limited to every 5 years	2				2				2	2	2	1				2				2				2	2																2	2	1	6	Teledentistry visit (real-time synchronous encounter) with Dental provider covered once per benefit plan year.	2				2				2	2
H3653	803	0	1	01	01	H3653_803_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3653	806	0	2	01	01	H3653_806_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3653	809	0	1	01	01	H3653_809_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3655	041	0	1	02	01	H3655_041_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	1	1	02	01	H3655_045_1	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	2	1	02	01	H3655_045_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	3	1	02	01	H3655_045_3	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	045	4	1	02	01	H3655_045_4	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H3655	801	0	1	01	01	H3655_801_0	5	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3655	803	0	1	01	01	H3655_803_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3655	805	0	2	01	01	H3655_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3655	806	0	2	01	01	H3655_806_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3655	808	0	1	01	01	H3655_808_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3655	810	0	2	01	01	H3655_810_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3660	028	0	1	02	01	H3660_028_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per five years.	1	70	70	70	2				2	2																															4	2	1	6	Once per five years.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	029	0	1	02	01	H3660_029_0	7	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per five years.	1	70	70	70	2				2	2																															4	2	1	6	Once per 5 year period.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	044	0	1	01	01	H3660_044_0	7	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per five years.	1	70	70	70	2				2	2																															4	2	1	6	Once per five years.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	050	0	1	01	01	H3660_050_0	7	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		0	20	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	3													2	2	4	2	1	6	Once per five years.	1	20	20	20	2				2	2																															4	2	1	6	Once per 5 year period.	1	20	20	20	2				2	2	4	2	1	6	Simple extractions and covered oral surgery services are payable once per tooth per lifetime.	3		0	20	2				2	2																4	1				2				2				2	2
H3660	052	1	1	01	01	H3660_052_1	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		0	50	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	3													2	2	4	2	1	6	Once per five years.	1	50	50	50	2				2	2																															4	2	1	6	Once per 5 year period.	1	50	50	50	2				2	2	4	2	1	6	Simple extractions and covered oral surgery services are payable once per tooth per lifetime.	3		0	50	2				2	2																4	1				2				2				2	2
H3660	052	2	1	01	01	H3660_052_2	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		0	50	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime	2				2				2	2	3													2	2	4	2	1	6	Once per five years.	1	50	50	50	2				2	2																															4	2	1	6	Once per 5 year period.	1	50	50	50	2				2	2	4	2	1	6	Simple extractions and covered oral surgery services are payable once per tooth per lifetime.	3		0	50	2				2	2																4	1				2				2				2	2
H3660	053	1	1	01	01	H3660_053_1	6	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		0	40	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	4	2	1	6	Some benefits are once per 24 months, twice per year or once per lifetime.	2				2				2	2	2	2	1	6	Some services are unlimited, once or twice per 36 months or once per five years.	3		0	40	2				2	2																															2	2	1	6	Some services once per 5 year period. Some are unlimited.	3		0	40	2				2	2	4	2	1	6	Some benefits are unlimited and some are once per tooth per lifetime.	3		0	40	2				2	2																4	1				2				2				2	2
H3660	053	2	1	01	01	H3660_053_2	5	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		0	40	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	2				2				2	2	4	2	1	6	Some benefits are once per 24 months, twice per year or once per lifetime.	2				2				2	2	2	2	1	6	Some services are unlimited, once or twice per 36 months or once per five years.	3		0	40	2				2	2																															2	2	1	6	Some services once per 5 year period. Some are unlimited.	3		0	40	2				2	2	4	2	1	6	Some benefits are unlimited and some are once per tooth per lifetime.	3		0	40	2				2	2																4	1				2				2				2	2
H3660	057	0	1	01	01	H3660_057_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are payable once per calendar year. Full Mouth X-Rays/Panoramic Films are payable once every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				3		50	70	2				2	2	2	2	1	6	Endodontic services are covered once per tooth per lifetime.	1	50	50	50	2				2	2	3													2	2	4	2	1	6	Once per 5 years.	1	70	70	70	2				2	2																															4	2	1	6	Once per five years.	1	70	70	70	2				2	2	4	2	1	6	Once per tooth per lifetime.	3		50	70	2				2	2																4	1				2				2				2	2
H3660	801	0	1	01	01	H3660_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3660	802	0	1	01	01	H3660_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3660	805	0	1	02	01	H3660_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3660	806	0	1	02	01	H3660_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3664	014	0	1	02	01	H3664_014_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1100.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H3664	017	0	1	02	01	H3664_017_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H3664	020	0	1	02	01	H3664_020_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H3664	021	0	1	02	01	H3664_021_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H3664	801	0	1	02	01	H3664_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3664	802	0	1	02	01	H3664_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3664	803	0	1	02	01	H3664_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3664	805	0	2	02	01	H3664_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3664	806	0	2	02	01	H3664_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3664	807	0	1	02	01	H3664_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3668	013	0	1	01	01	H3668_013_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	018	1	1	01	01	H3668_018_1	6	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	018	2	1	01	01	H3668_018_2	6	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	019	1	1	01	01	H3668_019_1	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	019	2	1	01	01	H3668_019_2	8	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	020	0	1	01	01	H3668_020_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	022	0	1	01	01	H3668_022_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	023	0	1	01	01	H3668_023_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	025	0	1	01	01	H3668_025_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	026	0	1	01	01	H3668_026_0	6	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	029	0	1	01	01	H3668_029_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	030	0	1	01	01	H3668_030_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2																																																																																											2	2	1	6	1 tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Frequency is unlimited or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	031	0	1	01	01	H3668_031_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2																																																																																											2	2	1	6	1 tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Frequency is unlimited or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3668	802	0	1	01	01	H3668_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3668	803	0	1	01	01	H3668_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3668	804	0	1	01	01	H3668_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3668	811	0	1	01	01	H3668_811_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3668	812	0	1	01	01	H3668_812_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3672	013	0	1	01	01	H3672_013_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	014	0	1	01	01	H3672_014_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. one panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1500.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	019	0	1	01	01	H3672_019_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	One per tooth every one - five years, depending on services.	2				2				2	2	2	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year	2				2				2	2	2	2	1	6	One - two treatments every one - three calendar years, depending on service.	2				2				2	2	2	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															2	2	1	6	One crown per tooth every five calendar years.	2				2				2	2	2	1				2				2				2	2																														
H3672	020	0	1	01	01	H3672_020_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	021	0	1	01	01	H3672_021_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1500.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	023	0	1	01	01	H3672_023_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1000.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	024	0	1	01	01	H3672_024_0	4	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		1500.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		0	50	2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	3		0	50	2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	3		0	50	2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		0	50	2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	3		0	50	2				2	2	4	1				3		0	50	2				2	2																														
H3672	805	0	1	01	01	H3672_805_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3706	001	0	1	01	01	H3706_001_0	4	2				2				1	40.00	40.00	40.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	009	0	1	01	01	H3706_009_0	3	2				2				1	35.00	35.00	35.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	023	0	1	01	01	H3706_023_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	024	0	1	01	01	H3706_024_0	6	2				2				1	20.00	20.00	20.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	025	0	1	01	01	H3706_025_0	5	2				2				1	35.00	35.00	35.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				2				2				2	2
H3706	028	0	1	01	01	H3706_028_0	5	2				1	20	20	20	2				2		1	1	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3706	029	0	1	01	01	H3706_029_0	5	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	1				2				2				2	2	2	2	1	6	Scaling in the presence of generalized moderate or severe gingival inflammation, full mouth - 2 every 12 monthsFull mouth debridement - one per 36 months	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3706	803	0	1	01	01	H3706_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3708	001	0	1	01	01	H3708_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3727	001	2	1	01	01	H3727_001_2	2	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	001	3	1	01	01	H3727_001_3	2	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	002	1	1	01	01	H3727_002_1	3	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	002	2	1	01	01	H3727_002_2	2	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3727	002	3	1	01	01	H3727_002_3	3	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H3740	001	0	1	20	08	H3740_001_0	2																																																																																																																																																																																																																																																																																																		
H3740	002	0	1	20	08	H3740_002_0	2																																																																																																																																																																																																																																																																																																		
H3748	003	0	1	01	01	H3748_003_0	2	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3748	801	0	1	01	01	H3748_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3755	001	0	1	01	01	H3755_001_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1					2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth. Therapeutic pulpotomoy and pulpal debridement are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 2 every 12 months.	2				2				2	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months.  Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	002	0	1	01	01	H3755_002_0	5	2				2				1	5.00	5.00	5.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1					2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	1	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	1	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months. Periodontal maintenance is limited to 2 every 12 months.	2				2				2	1	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	1																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime	2				2				1	1																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	004	0	1	01	01	H3755_004_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1					2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2				2				2	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	005	0	1	01	01	H3755_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2				2				2	2	2	2	1	6	Bitewings (1-4 films) are  limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1					2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	1	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	1	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2				2				1	1	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	1																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime.	2				2				1	1																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.  Teledentistry, synchronus or asynchronus limited to 1 per date of service.	2				2				2	2
H3755	006	0	1	01	01	H3755_006_0	7	2				1	20	20	20	2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (1-4 films) are limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series are limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1					2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth per surface.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months.	2				2				1	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays.	2				2				2	2
H3755	007	0	1	01	01	H3755_007_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	6	Periodic, detailed and extensive problem focused, re-evaluation exams are limited to 2 per 12 months. Limited oral evaluation problem focused is limited to 3 per 12 months.	2				2				2	2	2	2	1	6	Bitewings (1-4 films) limited to 1 per 12 months. Panoramic images, vertical bitewings (7-8 images) and intraoral complete series limited to 1 per 36 months.	2				2				2	2																2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2	2	2	2	6	Limited to 2 (two) treatments per 12 month period.	2				2				2	2																1	1					2					2		2	2	1	6	Amalgam and resin fillings are limited to once per 24 months, per tooth. Protective restoration is limited to 1 per lifetime.	2				2				1	2	2	2	1	6	Root canals are limited to 1 per lifetime per tooth.	1	50	50	50	2				1	2	2	2	1	6	Scaling and root planing are limited to once per quadrant per 36 months. Full mouth debridement is limited to 1 per 36 months.	2				2				2	2	2	2	1	6	Removable partial and complete dentures are limited to 1 per 60 months. Adjustments are limited to 2 per 12 months. Repairs and replacement of broken teeth are limited to 1 per 12 months.	1	50	50	50	2				1	2																																														2	2	1	6	Extractions are limited to 1 per tooth per lifetime. Coronectomy is limited to 1 per tooth per lifetime.	2				2				1	2																2	2	1	6	Palliative treatment is only allowed with a limited oral evaluation and x-rays	2				2				2	2
H3755	801	0	1	01	01	H3755_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3777	002	0	1	01	01	H3777_002_0	9	2				2				1	40.00	40.00	40.00	2		1	2	1		250.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	2	1				2								2	2	1	2		750.00	3		2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2
H3794	002	0	1	02	01	H3794_002_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3794	004	0	1	02	01	H3794_004_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3794	006	0	1	02	01	H3794_006_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3800	001	0	1	01	01	H3800_001_0	4	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																																													
H3805	001	0	1	02	01	H3805_001_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3805	015	0	1	02	01	H3805_015_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	017	0	1	02	01	H3805_017_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	032	0	1	02	01	H3805_032_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	033	0	1	02	01	H3805_033_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	034	0	1	02	01	H3805_034_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	035	0	1	02	01	H3805_035_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3805	037	0	1	02	01	H3805_037_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	039	1	1	02	01	H3805_039_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	039	2	1	02	01	H3805_039_2	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	040	0	1	02	01	H3805_040_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	041	0	1	02	01	H3805_041_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3805	043	0	1	02	01	H3805_043_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H3805	044	0	1	02	01	H3805_044_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3805	045	0	1	02	01	H3805_045_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H3805	801	0	1	01	01	H3805_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3805	803	0	1	01	01	H3805_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3805	804	0	1	01	01	H3805_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3805	805	0	1	01	01	H3805_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3805	806	0	1	01	01	H3805_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3805	807	0	1	01	01	H3805_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3809	001	0	1	20	08	H3809_001_0	2																																																																																																																																																																																																																																																																																																		
H3809	002	0	1	20	08	H3809_002_0	2																																																																																																																																																																																																																																																																																																		
H3810	023	0	1	01	01	H3810_023_0	8	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H3811	003	0	1	01	01	H3811_003_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3814	007	0	1	01	01	H3814_007_0	10	2				1	20	20	20	2				2		2	2	1		250.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3814	030	0	1	01	01	H3814_030_0	9	2				1	20	20	20	2				2		2	2	1		400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3815	001	0	1	01	01	H3815_001_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2						2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H3815	008	0	1	01	01	H3815_008_0	7	2				2				2				2		1	2	2					2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																2						2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H3815	010	0	1	01	01	H3815_010_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2						2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H3815	011	0	1	01	01	H3815_011_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2						2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
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H3815	053	0	1	01	01	H3815_053_0	7	2				2				2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H3815	054	0	1	01	01	H3815_054_0	8	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																2						2					2		4	1				2				3		20.00	400.00	1	2	4	1				2				3		25.00	350.00	1	2	4	1				2				3		15.00	550.00	1	2	4	1				2				3		20.00	570.00	1	2																															4	1				2				3		40.00	400.00	1	2	4	1				2				3		25.00	250.00	1	2																														
H3815	055	0	1	01	01	H3815_055_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	1																4	2	1	4		2				2				1	1	4	2	1	4		2				2				1	1																																																																																																																																																																																		
H3815	056	0	1	01	01	H3815_056_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	1																4	2	1	4		2				2				1	1	4	2	1	4		2				2				1	1																																																																																																																																																																																		
H3815	801	0	1	01	01	H3815_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3815	802	0	1	01	01	H3815_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3815	803	0	1	01	01	H3815_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3815	804	0	1	01	01	H3815_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H3817	008	1	1	04	01	H3817_008_1	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	008	2	1	04	01	H3817_008_2	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	008	4	1	04	01	H3817_008_4	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	009	1	1	04	01	H3817_009_1	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	009	2	1	04	01	H3817_009_2	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	010	0	1	04	01	H3817_010_0	5	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	011	1	1	04	01	H3817_011_1	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	011	2	1	04	01	H3817_011_2	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	011	3	1	04	01	H3817_011_3	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H3817	801	0	1	04	01	H3817_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3817	802	0	1	04	01	H3817_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3817	803	0	1	04	01	H3817_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3817	804	0	1	04	01	H3817_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	001	0	1	01	01	H3822_001_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3822	002	0	1	01	01	H3822_002_0	5	2				2				1	35.00	35.00	35.00	2		2	2																																																																																																																																																																																																																																																																																		
H3822	007	0	1	02	01	H3822_007_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3822	008	0	1	02	01	H3822_008_0	5	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H3822	012	0	1	01	01	H3822_012_0	5	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H3822	014	0	1	01	01	H3822_014_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H3822	801	0	1	01	01	H3822_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	802	0	1	01	01	H3822_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	805	0	1	01	01	H3822_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	806	0	1	01	01	H3822_806_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	809	0	1	01	01	H3822_809_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	810	0	1	01	01	H3822_810_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	813	0	1	01	01	H3822_813_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	814	0	1	01	01	H3822_814_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	815	0	1	01	01	H3822_815_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	816	0	1	01	01	H3822_816_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	817	0	1	01	01	H3822_817_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3822	818	0	1	01	01	H3822_818_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3828	001	0	1	04	01	H3828_001_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H3828	801	0	1	04	01	H3828_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3828	802	0	1	04	01	H3828_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3832	007	0	1	04	01	H3832_007_0	5	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	008	0	1	04	01	H3832_008_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	009	0	1	04	01	H3832_009_0	5	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	010	0	1	04	01	H3832_010_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																													2	2	4	3		2				1	0.00	0.00	0.00	2	2																														
H3832	801	0	1	04	01	H3832_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3832	802	0	1	04	01	H3832_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3832	805	0	1	04	01	H3832_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3832	807	0	1	04	01	H3832_807_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3864	002	0	1	02	01	H3864_002_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	006	0	1	01	01	H3864_006_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	014	0	1	02	01	H3864_014_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	024	0	1	02	01	H3864_024_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	027	0	1	01	01	H3864_027_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	029	0	1	02	01	H3864_029_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	030	0	1	02	01	H3864_030_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H3864	034	0	1	02	01	H3864_034_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	036	0	1	02	01	H3864_036_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	040	0	1	01	01	H3864_040_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3864	041	0	1	01	01	H3864_041_0	5	2				2				1	35.00	35.00	35.00	2		1	2																																																																																																																																																																																																																																																																																		
H3864	043	0	1	01	01	H3864_043_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3864	045	0	1	01	01	H3864_045_0	7	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3864	801	0	1	01	01	H3864_801_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3864	803	0	1	01	01	H3864_803_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3864	805	0	1	02	01	H3864_805_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3864	806	0	1	02	01	H3864_806_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3868	001	0	1	02	01	H3868_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H3890	001	0	1	04	01	H3890_001_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3890	002	0	1	04	01	H3890_002_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3890	005	0	1	04	01	H3890_005_0	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	•Periodic oral exams, Extensive oral exam – problem focused, Re-Evaluation – limited problem focused – two per calendar year•Limited Oral Exam – 3 per calendar Year•Comprehensive Oral Exam or Comprehensive Periodontal Exam – One per 3 years per provider or location	2				2				2	2	2	2	1	6	•Intraoral or Intraoral Tomosynthesis complete series of radiographic images, one set of vertical bitewing-7 to 8 films, panoramic radiographic image- one every 3 years•Intraoral-occlusal radiographic image-two every 2 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H3890	801	0	1	04	01	H3890_801_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3907	002	0	1	01	01	H3907_002_0	13	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	006	0	1	01	01	H3907_006_0	18	2				2				1	10.00	10.00	10.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every year. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2		5500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	037	0	1	01	01	H3907_037_0	16	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3225.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	1	1	01	01	H3907_057_1	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	2	1	01	01	H3907_057_2	17	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	3	1	01	01	H3907_057_3	17	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	4	1	01	01	H3907_057_4	15	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	5	1	01	01	H3907_057_5	16	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	6	1	01	01	H3907_057_6	16	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	057	7	1	01	01	H3907_057_7	16	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	058	1	1	01	01	H3907_058_1	16	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																															2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																														
H3907	058	2	1	01	01	H3907_058_2	17	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																															2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																														
H3907	058	3	1	01	01	H3907_058_3	17	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																															2	1				1	30	30	30	2				2	2	2	1				1	30	30	30	2				2	2																														
H3907	059	1	1	01	01	H3907_059_1	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	2	1	01	01	H3907_059_2	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	3	1	01	01	H3907_059_3	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	4	1	01	01	H3907_059_4	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	059	5	1	01	01	H3907_059_5	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		4500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H3907	801	0	1	01	01	H3907_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3907	802	0	1	01	01	H3907_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3907	803	0	1	01	01	H3907_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3907	804	0	1	01	01	H3907_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3908	001	0	1	20	08	H3908_001_0	2																																																																																																																																																																																																																																																																																																		
H3908	002	0	1	20	08	H3908_002_0	2																																																																																																																																																																																																																																																																																																		
H3909	001	0	1	04	01	H3909_001_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	007	0	1	04	01	H3909_007_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	009	0	1	04	01	H3909_009_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	018	0	1	04	01	H3909_018_0	6	2				2				1	0.00	0.00	0.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1000.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	0	0	0	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	0	0	0	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	0	0	0	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	0	0	0	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	0	0	0	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	0	0	0	2				2	2	2	1				1	0	0	0	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	020	0	1	04	01	H3909_020_0	6	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1000.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	50	50	50	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	50	50	50	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3909	801	0	1	04	01	H3909_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3909	802	0	1	04	01	H3909_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	001	0	1	04	01	H3916_001_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	002	0	1	04	01	H3916_002_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	005	0	1	04	01	H3916_005_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	012	0	1	04	01	H3916_012_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	015	0	1	04	01	H3916_015_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	018	0	1	04	01	H3916_018_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	022	0	1	04	01	H3916_022_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	024	0	1	04	01	H3916_024_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	032	0	1	04	01	H3916_032_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	033	0	1	04	01	H3916_033_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3916	035	1	1	04	01	H3916_035_1	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	035	2	1	04	01	H3916_035_2	7	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		3		0	10	2				2	2
H3916	037	2	1	04	01	H3916_037_2	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	037	4	1	04	01	H3916_037_4	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	037	5	1	04	01	H3916_037_5	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	037	6	1	04	01	H3916_037_6	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	037	7	1	04	01	H3916_037_7	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	037	8	1	04	01	H3916_037_8	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	038	0	1	04	01	H3916_038_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	039	0	1	04	01	H3916_039_0	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	041	1	1	04	01	H3916_041_1	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	041	2	1	04	01	H3916_041_2	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	041	3	1	04	01	H3916_041_3	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	043	0	1	04	01	H3916_043_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	056	0	1	04	01	H3916_056_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	057	0	1	04	01	H3916_057_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	058	0	1	04	01	H3916_058_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	059	1	1	04	01	H3916_059_1	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		3		0	10	2				2	2
H3916	059	2	1	04	01	H3916_059_2	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H3916	060	1	1	04	01	H3916_060_1	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		3		0	25	2				2	2
H3916	060	2	1	04	01	H3916_060_2	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		3		0	25	2				2	2
H3916	060	3	1	04	01	H3916_060_3	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		3		0	25	2				2	2
H3916	060	4	1	04	01	H3916_060_4	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		3		0	25	2				2	2
H3916	060	5	1	04	01	H3916_060_5	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		3		0	25	2				2	2
H3916	060	6	1	04	01	H3916_060_6	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	061	1	1	04	01	H3916_061_1	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	25	25	25	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	25	25	25	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	25	25	25	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	25	25	25	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	25	25	25	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	25	25	25	2				2	2																2	2	2	3		3		0	25	2				2	2
H3916	061	2	1	04	01	H3916_061_2	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	062	0	1	04	01	H3916_062_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	063	0	1	04	01	H3916_063_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	064	0	1	04	01	H3916_064_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	065	0	1	04	01	H3916_065_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	066	0	1	04	01	H3916_066_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H3916	067	0	1	04	01	H3916_067_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3916	801	0	1	04	01	H3916_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	802	0	1	04	01	H3916_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	804	0	1	04	01	H3916_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	805	0	1	04	01	H3916_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	806	0	1	04	01	H3916_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	807	0	1	04	01	H3916_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	808	0	1	04	01	H3916_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	809	0	1	04	01	H3916_809_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3916	810	0	1	04	01	H3916_810_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3917	001	0	1	20	08	H3917_001_0	2																																																																																																																																																																																																																																																																																																		
H3917	002	0	1	20	08	H3917_002_0	2																																																																																																																																																																																																																																																																																																		
H3918	001	0	1	20	08	H3918_001_0	2																																																																																																																																																																																																																																																																																																		
H3918	002	0	1	20	08	H3918_002_0	2																																																																																																																																																																																																																																																																																																		
H3919	001	0	1	20	08	H3919_001_0	2																																																																																																																																																																																																																																																																																																		
H3919	002	0	1	20	08	H3919_002_0	2																																																																																																																																																																																																																																																																																																		
H3923	013	0	1	04	01	H3923_013_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	017	0	1	04	01	H3923_017_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	044	1	1	04	01	H3923_044_1	3	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	044	2	1	04	01	H3923_044_2	3	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	044	3	1	04	01	H3923_044_3	3	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	044	4	1	04	01	H3923_044_4	3	2				2				1	25.00	25.00	25.00	2		2	2	1	2	3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	1	1	04	01	H3923_045_1	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	2	1	04	01	H3923_045_2	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	3	1	04	01	H3923_045_3	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	4	1	04	01	H3923_045_4	5	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	045	5	1	04	01	H3923_045_5	5	2				2				1	30.00	30.00	30.00	2		2	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3923	046	1	1	04	01	H3923_046_1	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	4000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	046	2	1	04	01	H3923_046_2	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	4000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	046	3	1	04	01	H3923_046_3	4	2				2				1	15.00	15.00	15.00	2		2	2	1	2	4000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	046	4	1	04	01	H3923_046_4	4	2				2				1	25.00	25.00	25.00	2		2	2	1	2	4000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	1	1	04	01	H3923_047_1	4	2				2				1	15.00	15.00	15.00	2		2	2	1	2	5000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	2	1	04	01	H3923_047_2	4	2				2				1	15.00	15.00	15.00	2		2	2	1	2	5000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	3	1	04	01	H3923_047_3	4	2				2				1	15.00	15.00	15.00	2		2	2	1	2	5000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	4	1	04	01	H3923_047_4	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	5000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	047	5	1	04	01	H3923_047_5	4	2				2				1	15.00	15.00	15.00	2		2	2	1	2	5000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam & composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3923	048	2	1	04	01	H3923_048_2	3	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1200.00	3		2				2					1	100110	0.00	0.00	0.00	2		2	2	2	3		2								2	2																															2	2	2	3		2								2	2	2	2	2	3		2								2	2																																																																																																																																																																																		
H3923	048	3	1	04	01	H3923_048_3	3	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1200.00	3		2				2					1	100110	0.00	0.00	0.00	2		2	2	2	3		2								2	2																															2	2	2	3		2								2	2	2	2	2	3		2								2	2																																																																																																																																																																																		
H3923	048	5	1	04	01	H3923_048_5	3	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1200.00	3		2				2					1	100110	0.00	0.00	0.00	2		2	2	2	3		2								2	2																															2	2	2	3		2								2	2	2	2	2	3		2								2	2																																																																																																																																																																																		
H3923	801	0	1	04	01	H3923_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3923	802	0	1	04	01	H3923_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3923	817	0	1	04	01	H3923_817_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3923	818	0	1	04	01	H3923_818_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3923	819	0	1	04	01	H3923_819_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3923	820	0	1	04	01	H3923_820_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3923	832	0	1	04	01	H3923_832_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3924	059	21	1	04	01	H3924_059_21	3	2				2				1	25.00	25.00	25.00	2		1	2																																																																																																																																																																																																																																																																																		
H3924	059	22	1	04	01	H3924_059_22	3	2				2				1	25.00	25.00	25.00	2		1	2																																																																																																																																																																																																																																																																																		
H3924	065	0	1	04	01	H3924_065_0	3	2				2				1	35.00	35.00	35.00	2		1	2																																																																																																																																																																																																																																																																																		
H3924	804	0	1	04	01	H3924_804_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3924	805	0	1	04	01	H3924_805_0	2	2				2				1	35.00	35.00	35.00	2		1	2																																																																																																																																																																																																																																																																																		
H3925	001	0	1	20	08	H3925_001_0	2																																																																																																																																																																																																																																																																																																		
H3925	002	0	1	20	08	H3925_002_0	2																																																																																																																																																																																																																																																																																																		
H3928	001	0	1	01	01	H3928_001_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3928	801	0	1	01	01	H3928_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3928	803	0	1	01	01	H3928_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3931	004	0	1	02	01	H3931_004_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3931	091	0	1	02	01	H3931_091_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	092	0	1	01	01	H3931_092_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	094	0	1	01	01	H3931_094_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	095	0	1	02	01	H3931_095_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	099	0	1	02	01	H3931_099_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	100	0	1	02	01	H3931_100_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	101	0	1	02	01	H3931_101_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	102	0	1	01	01	H3931_102_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	107	0	1	02	01	H3931_107_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	108	0	1	01	01	H3931_108_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	109	0	1	02	01	H3931_109_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	126	0	1	01	01	H3931_126_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	129	0	1	01	01	H3931_129_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	143	0	1	02	01	H3931_143_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	146	0	1	01	01	H3931_146_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	151	0	1	01	01	H3931_151_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	152	0	1	01	01	H3931_152_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	153	0	1	02	01	H3931_153_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	154	0	1	02	01	H3931_154_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	157	0	1	01	01	H3931_157_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	158	0	1	02	01	H3931_158_0	2	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	160	0	1	01	01	H3931_160_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	162	0	1	01	01	H3931_162_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	175	0	1	01	01	H3931_175_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3931	188	0	1	01	01	H3931_188_0	3	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	190	0	1	02	01	H3931_190_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	191	0	1	01	01	H3931_191_0	3	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3931	196	0	1	01	01	H3931_196_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3931	197	0	1	01	01	H3931_197_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3931	801	0	1	01	01	H3931_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3931	804	0	1	01	01	H3931_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3933	001	0	1	20	08	H3933_001_0	2																																																																																																																																																																																																																																																																																																		
H3933	002	0	1	20	08	H3933_002_0	2																																																																																																																																																																																																																																																																																																		
H3942	001	0	1	20	08	H3942_001_0	2																																																																																																																																																																																																																																																																																																		
H3942	002	0	1	20	08	H3942_002_0	2																																																																																																																																																																																																																																																																																																		
H3949	009	0	1	01	01	H3949_009_0	9	2				1	20	20	20	2				2		1	2	1		2600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	024	0	1	01	01	H3949_024_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	030	0	1	01	01	H3949_030_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	031	0	1	01	01	H3949_031_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	035	0	1	01	01	H3949_035_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	045	0	1	01	01	H3949_045_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	047	0	1	01	01	H3949_047_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	048	0	1	01	01	H3949_048_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	049	0	1	01	01	H3949_049_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H3949	052	0	1	01	01	H3949_052_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		1700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	053	0	1	01	01	H3949_053_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	054	0	1	01	01	H3949_054_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		950.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H3949	804	0	1	01	01	H3949_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H3952	008	0	1	01	01	H3952_008_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3952	020	0	1	01	01	H3952_020_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3952	045	0	1	01	01	H3952_045_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3952	048	0	1	01	01	H3952_048_0	5	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	049	0	1	01	01	H3952_049_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	050	0	1	01	01	H3952_050_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	051	0	1	01	01	H3952_051_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	053	0	1	02	01	H3952_053_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	2	1	6	Subject to limitations in note.	3		20	40	2				2	2																2	2	1	6	#16c10, Adjunctive General Services: Anesthesia and palliative treatment covered as needed.	2				1	0.00	0.00	0.00	2	2
H3952	054	0	1	02	01	H3952_054_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	2	1	6	Subject to limitations in note.	3		20	40	2				2	2																2	2	1	6	#16c10, Adjunctive General Services: Anesthesia and palliative treatment covered as needed.	2				1	0.00	0.00	0.00	2	2
H3952	055	0	1	01	01	H3952_055_0	7	2				2				1	38.00	38.00	38.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in the note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		2000.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	10	10	10	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	10	10	10	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	10	10	10	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	10	10	10	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	10	10	10	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	10	10	10	2				2	2	2	1				1	10	10	10	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	059	0	1	01	01	H3952_059_0	6	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		2000.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3952	060	0	1	02	01	H3952_060_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2		2000.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	0	0	0	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	0	0	0	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	0	0	0	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	0	0	0	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	0	0	0	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	0	0	0	2				2	2	2	1				1	0	0	0	2				2	2																2	1				1	0	0	0	2				2	2
H3952	802	0	1	01	01	H3952_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3952	804	0	1	01	01	H3952_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3954	097	0	1	01	01	H3954_097_0	3	2				1	20	20	20	2				2		1	2	1		4500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	157	21	1	01	01	H3954_157_21	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	157	22	1	01	01	H3954_157_22	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	157	23	1	01	01	H3954_157_23	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	158	13	1	01	01	H3954_158_13	3	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	158	14	1	01	01	H3954_158_14	3	2				2				1	35.00	35.00	35.00	2		1	2	1		750.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	160	0	1	01	01	H3954_160_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	161	0	1	01	01	H3954_161_0	3	2				2				1	30.00	30.00	30.00	2		1	2																																																																																																																																																																																																																																																																																		
H3954	162	0	1	01	01	H3954_162_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	163	0	1	01	01	H3954_163_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		100.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	1				2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H3954	801	0	1	01	01	H3954_801_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3954	802	0	1	01	01	H3954_802_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3954	805	0	1	01	01	H3954_805_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3954	806	0	1	01	01	H3954_806_0	1	2				2				2				2		1	2	2					2				2					2					2																	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H3957	031	0	1	02	01	H3957_031_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	042	1	1	01	01	H3957_042_1	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	042	2	1	01	01	H3957_042_2	7	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	042	4	1	01	01	H3957_042_4	7	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	042	5	1	01	01	H3957_042_5	7	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	042	6	1	01	01	H3957_042_6	7	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	042	7	1	01	01	H3957_042_7	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	043	1	1	02	01	H3957_043_1	5	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	043	2	1	02	01	H3957_043_2	4	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	044	1	1	02	01	H3957_044_1	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	044	4	1	02	01	H3957_044_4	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	045	1	1	02	01	H3957_045_1	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	045	2	1	02	01	H3957_045_2	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	046	1	1	02	01	H3957_046_1	7	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	046	2	1	02	01	H3957_046_2	7	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H3957	047	1	1	01	01	H3957_047_1	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	047	2	1	01	01	H3957_047_2	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H3957	047	3	1	01	01	H3957_047_3	6	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth.	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	047	4	1	01	01	H3957_047_4	6	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth.	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	047	5	1	01	01	H3957_047_5	6	2				2				1	30.00	30.00	30.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth.	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	048	0	1	01	01	H3957_048_0	6	2				2				1	10.00	10.00	10.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years.	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	1	1	01	01	H3957_049_1	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	2	1	01	01	H3957_049_2	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	3	1	01	01	H3957_049_3	6	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	4	1	01	01	H3957_049_4	6	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	5	1	01	01	H3957_049_5	6	2				2				1	30.00	30.00	30.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	6	1	01	01	H3957_049_6	6	2				2				1	35.00	35.00	35.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	049	7	1	01	01	H3957_049_7	6	2				2				1	35.00	35.00	35.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	1	1	01	01	H3957_050_1	7	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	2	1	01	01	H3957_050_2	7	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	3	1	01	01	H3957_050_3	7	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	4	1	01	01	H3957_050_4	6	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	050	5	1	01	01	H3957_050_5	6	2				2				1	25.00	25.00	25.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime.	2				2				2	2																2	2	2	3		2				2				2	2
H3957	805	0	1	01	01	H3957_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	806	0	1	01	01	H3957_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	808	0	1	01	01	H3957_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	810	0	1	01	01	H3957_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	811	0	1	01	01	H3957_811_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	812	0	1	01	01	H3957_812_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	813	0	1	02	01	H3957_813_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	814	0	1	02	01	H3957_814_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	815	0	1	02	01	H3957_815_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	816	0	1	01	01	H3957_816_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	817	0	1	02	01	H3957_817_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3957	818	0	1	01	01	H3957_818_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3959	001	0	1	02	01	H3959_001_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	002	0	1	02	01	H3959_002_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	010	0	1	02	01	H3959_010_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	011	0	1	02	01	H3959_011_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	032	0	1	02	01	H3959_032_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	033	0	1	02	01	H3959_033_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	035	0	1	01	01	H3959_035_0	2	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	036	0	1	01	01	H3959_036_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	037	0	1	02	01	H3959_037_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	039	0	1	02	01	H3959_039_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	041	0	1	02	01	H3959_041_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	052	0	1	02	01	H3959_052_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	053	0	1	02	01	H3959_053_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	055	0	1	01	01	H3959_055_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	056	0	1	01	01	H3959_056_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	066	0	1	01	01	H3959_066_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	069	0	1	01	01	H3959_069_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	070	0	1	01	01	H3959_070_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	071	0	1	01	01	H3959_071_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	072	0	1	01	01	H3959_072_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	073	0	1	01	01	H3959_073_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H3959	074	0	1	01	01	H3959_074_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	075	0	1	01	01	H3959_075_0	2	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	076	0	1	01	01	H3959_076_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	083	0	1	01	01	H3959_083_0	2	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	084	0	1	01	01	H3959_084_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	085	0	1	01	01	H3959_085_0	2	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H3959	804	0	1	01	01	H3959_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H3962	001	0	1	01	01	H3962_001_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months,only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	004	0	1	01	01	H3962_004_0	5	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month; Crowns (inlays and onlays)-1 per tooth every 5 years; Crown repairs and recementing of crowns-1 per 36 months but not within 5 years of placement	1	50	50	50	2				2	2	2	2	1	6	Root canal - 1 per tooth per lifetimeRoot canal retreatment - 1 per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		1	50	50	50	2				2	2	2	2	1	6	Complete or Partial Dentures - 1 every 5 years; Denture repairs, reline&rebase-1 per 24 months, only after 24 months from date of placement	1	50	50	50	2				2	2																															2	2	1	6	Bridges-1 every 5 years	1	50	50	50	2				2	2	2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H3962	022	1	1	01	01	H3962_022_1	3	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	2	1	01	01	H3962_022_2	3	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	3	1	01	01	H3962_022_3	3	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	4	1	01	01	H3962_022_4	3	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	022	5	1	01	01	H3962_022_5	3	2				2				1	20.00	20.00	20.00	2		2	2	1		3000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	2	6	Bite-wing X-rays - twice per year (up to 8 per instance)All other covered X-rays - one every 5 years	2								2	2																2	2	2	3		2								2	2	2	2	2	3		2								2	2																1	1					2					2		2	2	1	6	Fillings (amalgam&composite)-1 per tooth per 24 month;	1	50	50	50	2				2	2																																																																																											2	2	1	6	Simple extractions only - 1 per tooth per lifetime	1	50	50	50	2				2	2																														
H3962	801	0	1	01	01	H3962_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3962	802	0	1	01	01	H3962_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3962	813	0	1	01	01	H3962_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3962	817	0	1	01	01	H3962_817_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3962	828	0	1	01	01	H3962_828_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3975	001	0	1	04	01	H3975_001_0	7	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H3975	002	0	1	04	01	H3975_002_0	7	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H3975	004	0	1	04	01	H3975_004_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H3979	001	0	1	01	01	H3979_001_0	6	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H3979	801	0	1	01	01	H3979_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3979	803	0	1	01	01	H3979_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3979	805	0	1	01	01	H3979_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H3991	001	0	1	20	08	H3991_001_0	2																																																																																																																																																																																																																																																																																																		
H3991	002	0	1	20	08	H3991_002_0	2																																																																																																																																																																																																																																																																																																		
H4003	009	0	1	01	01	H4003_009_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	017	0	1	01	01	H4003_017_0	6	2				2				2				2		1	2																																																																																																																1	2		3500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	019	0	1	02	01	H4003_019_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		3500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	034	0	1	02	01	H4003_034_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	055	0	1	02	01	H4003_055_0	6	2				3		0	20	2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																																																																																																																																																																			
H4003	058	0	1	01	01	H4003_058_0	5	2				2				2				2		1	2																																																																																																																1	2		1500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4003	806	0	1	02	01	H4003_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	807	0	1	02	01	H4003_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	820	0	1	02	01	H4003_820_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	821	0	1	02	01	H4003_821_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	822	0	1	02	01	H4003_822_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	823	0	1	02	01	H4003_823_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	824	0	1	02	01	H4003_824_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	825	0	1	02	01	H4003_825_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	826	0	1	02	01	H4003_826_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	827	0	1	02	01	H4003_827_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	828	0	1	02	01	H4003_828_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	829	0	1	02	01	H4003_829_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	830	0	1	02	01	H4003_830_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4003	831	0	1	02	01	H4003_831_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	048	0	1	01	01	H4004_048_0	5	2				2				2				2		1	2																																																																																																																1	2		2000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	056	0	1	02	01	H4004_056_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	065	0	1	02	01	H4004_065_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		2000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	066	0	1	02	01	H4004_066_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	068	0	1	01	01	H4004_068_0	5	2				3		0	20	2				2		1	2																																																																																																																1	2		1000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2
H4004	069	0	1	01	01	H4004_069_0	5	2				3		0	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4004	070	0	1	02	01	H4004_070_0	5	2				3		0	20	2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	3		0	20	2				1	2
H4004	071	0	1	02	01	H4004_071_0	5	2				3		0	20	2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																																																																																																																																																																			
H4004	072	1	1	01	01	H4004_072_1	5	2				2				2				2		1	2																																																																																																																1	2		2000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	072	2	1	01	01	H4004_072_2	5	2				2				2				2		1	2																																																																																																																1	2		2000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	072	3	1	01	01	H4004_072_3	5	2				2				2				2		1	2																																																																																																																1	2		2000.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																															2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	073	1	1	02	01	H4004_073_1	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	073	2	1	02	01	H4004_073_2	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	073	3	1	02	01	H4004_073_3	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	6	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2	1	2		1500.00	3		2					2		2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2	2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2																2	2	1	6	PERIODICITY VARIES BY SERVICE	2				2				1	2
H4004	817	0	1	02	01	H4004_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	818	0	1	02	01	H4004_818_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	819	0	1	02	01	H4004_819_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	820	0	1	02	01	H4004_820_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	822	0	1	02	01	H4004_822_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	823	0	1	02	01	H4004_823_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	824	0	1	02	01	H4004_824_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	825	0	1	02	01	H4004_825_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	826	0	1	02	01	H4004_826_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	827	0	1	02	01	H4004_827_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	828	0	1	02	01	H4004_828_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	829	0	1	02	01	H4004_829_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	830	0	1	02	01	H4004_830_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4004	831	0	1	02	01	H4004_831_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4005	004	0	1	04	01	H4005_004_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series ofintraoral radiographic images including a pair of bitewing X-Rays,every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2	2	1000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H4005	801	0	1	04	01	H4005_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4005	802	0	1	04	01	H4005_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4005	804	0	1	04	01	H4005_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4005	807	0	1	04	01	H4005_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4005	808	0	1	04	01	H4005_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4005	809	0	1	04	01	H4005_809_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4005	810	0	1	04	01	H4005_810_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4026	001	0	1	01	01	H4026_001_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1500.00	3		2					2		2	1				1	50	50	50	2				1	2																2	2	2	3		2				2				1	2																																																													2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H4026	002	0	1	01	01	H4026_002_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		200.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4032	001	0	1	02	01	H4032_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4032	002	0	1	02	01	H4032_002_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4036	008	0	1	04	01	H4036_008_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																		
H4036	017	0	1	04	01	H4036_017_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	022	0	1	04	01	H4036_022_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	024	0	1	04	01	H4036_024_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	025	0	1	04	01	H4036_025_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1200.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	026	0	1	04	01	H4036_026_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	030	0	1	04	01	H4036_030_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	034	0	1	04	01	H4036_034_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	036	0	1	04	01	H4036_036_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	040	0	1	04	01	H4036_040_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4036	801	0	1	04	01	H4036_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	802	0	1	04	01	H4036_802_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	805	0	1	04	01	H4036_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	806	0	2	04	01	H4036_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	807	0	1	04	01	H4036_807_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	809	0	2	04	01	H4036_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	810	0	2	04	01	H4036_810_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	812	0	1	04	01	H4036_812_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	813	0	1	04	01	H4036_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	814	0	1	04	01	H4036_814_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	819	0	1	04	01	H4036_819_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	820	0	1	04	01	H4036_820_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	821	0	2	04	01	H4036_821_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	822	0	2	04	01	H4036_822_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	823	0	1	04	01	H4036_823_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	824	0	1	04	01	H4036_824_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	825	0	2	04	01	H4036_825_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	826	0	2	04	01	H4036_826_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	827	0	1	04	01	H4036_827_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	828	0	1	04	01	H4036_828_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	829	0	2	04	01	H4036_829_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4036	830	0	2	04	01	H4036_830_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4045	001	0	1	01	01	H4045_001_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4053	001	0	1	20	08	H4053_001_0	2																																																																																																																																																																																																																																																																																																		
H4053	002	0	1	20	08	H4053_002_0	2																																																																																																																																																																																																																																																																																																		
H4054	001	0	1	01	01	H4054_001_0	6	2				1	20	20	20	2				2		2	2	1		5000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		1	20	20	20	2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4057	001	0	1	01	01	H4057_001_0	4	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				2				1	1																2	2	1	1		2				2				1	1	2	2	1	6	Every 5 calendar years	2				2				1	1																															2	2	1	6	Every five (5) calendar years	2				2				1	1																																													
H4073	001	0	1	02	01	H4073_001_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4073	002	0	1	02	01	H4073_002_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4073	003	0	1	02	01	H4073_003_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4073	004	0	1	02	01	H4073_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4074	001	0	1	20	08	H4074_001_0	2																																																																																																																																																																																																																																																																																																		
H4074	002	0	1	20	08	H4074_002_0	2																																																																																																																																																																																																																																																																																																		
H4091	001	0	1	04	01	H4091_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4091	002	0	1	04	01	H4091_002_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																														
H4091	003	0	1	04	01	H4091_003_0	4	2				1	20	20	20	2				2		1	2	1	2	750.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2																															1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				1	2																														
H4093	001	0	1	01	01	H4093_001_0	6	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4093	004	0	1	01	01	H4093_004_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4093	008	0	1	01	01	H4093_008_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4105	001	0	1	20	08	H4105_001_0	2																																																																																																																																																																																																																																																																																																		
H4105	002	0	1	20	08	H4105_002_0	2																																																																																																																																																																																																																																																																																																		
H4118	001	0	1	20	08	H4118_001_0	3																																																																																																																																																																																																																																																																																																		
H4118	002	0	1	20	08	H4118_002_0	2																																																																																																																																																																																																																																																																																																		
H4140	001	0	1	01	01	H4140_001_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	8	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	2	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	002	0	1	01	01	H4140_002_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	7	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	004	0	1	01	01	H4140_004_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	7	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2	2	2	1	1		2				2				1	2	2	2	4	3		2				2				1	2																														
H4140	012	0	1	01	01	H4140_012_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Periodontal root scaling and root planing - 1 per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	013	0	1	01	01	H4140_013_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	6	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	1	1		2				2				1	2	2	2	4	3		2				2				1	2																														
H4140	016	0	1	01	01	H4140_016_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Periodontal root scaling and root planing - 1 per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	017	0	1	01	01	H4140_017_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	7	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or Plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2	2	2	1	1		2				2				1	2	2	2	3	3		2				2				1	2																														
H4140	018	0	1	01	01	H4140_018_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																2	2	1	3		2				2				1	2																2	2	4	3		2				2				1	2																														
H4140	019	0	1	01	01	H4140_019_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	3	6	Plan covers 2 bitewing X-rays per year and 1 panoramic X-ray every 3 years	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	3		2				2				1	2																2	2	1	6	Plan covers periodontal scaling & root planing, one per quadrant per 2 years.	2				2				1	2	2	2	2	6	Plan covers 1 full upper and 1 full lower denture per 5 years or plan covers 1 upper partial and 1 lower partial denture per 5 years.	2				2				1	2																																														2	2	2	3		2				2				1	2																														
H4141	003	0	1	01	01	H4141_003_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	015	0	1	01	01	H4141_015_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	017	3	1	01	01	H4141_017_3	3	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	017	5	1	01	01	H4141_017_5	3	2				2				1	10.00	10.00	10.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4141	022	0	1	01	01	H4141_022_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H4141	023	0	1	01	01	H4141_023_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	024	0	1	01	01	H4141_024_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	025	0	1	01	01	H4141_025_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4141	801	0	1	01	01	H4141_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4141	802	0	1	01	01	H4141_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4141	805	0	1	01	01	H4141_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4141	806	0	1	01	01	H4141_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4142	001	0	1	20	08	H4142_001_0	2																																																																																																																																																																																																																																																																																																		
H4142	002	0	1	20	08	H4142_002_0	2																																																																																																																																																																																																																																																																																																		
H4152	004	0	1	01	01	H4152_004_0	6	2				1	20	20	20	2				2		2	2	1		1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4152	013	0	1	02	01	H4152_013_0	6	2				1	20	20	20	2				2		2	2	1		2000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4152	018	0	1	02	01	H4152_018_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4152	021	0	1	01	01	H4152_021_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4152	022	0	1	02	01	H4152_022_0	6	2				1	20	20	20	2				2		2	2	1		1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4152	023	0	1	02	01	H4152_023_0	6	2				1	20	20	20	2				2		2	2	1		500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H4152	815	0	1	02	01	H4152_815_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4152	817	0	1	01	01	H4152_817_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4158	001	0	1	01	01	H4158_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per visit	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 24 months	2				1	0.00	0.00	0.00	1	2
H4161	002	0	1	02	01	H4161_002_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	003	0	1	02	01	H4161_003_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	004	0	1	02	01	H4161_004_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		500.00	3		2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2																															2	1				2				2				1	2	4	1				2				2				1	2																4	1				2				2				1	2
H4161	005	0	1	02	01	H4161_005_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H4161	006	0	1	02	01	H4161_006_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H4161	007	0	1	02	01	H4161_007_0	5	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H4161	009	0	1	02	01	H4161_009_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		200.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	010	0	1	02	01	H4161_010_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	011	0	1	02	01	H4161_011_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	012	0	1	02	01	H4161_012_0	5	2				2				3		0.00	20.00	2		1	2	1		1200.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	013	0	1	02	01	H4161_013_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4161	014	0	1	02	01	H4161_014_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4161	015	0	1	02	01	H4161_015_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4161	016	0	1	02	01	H4161_016_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4161	017	0	1	02	01	H4161_017_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4172	001	0	1	01	01	H4172_001_0	4	2				1	20	20	20	2				2		1	2	1		1650.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H4172	003	0	1	01	01	H4172_003_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H4185	001	0	1	20	08	H4185_001_0	2																																																																																																																																																																																																																																																																																																		
H4185	002	0	1	20	08	H4185_002_0	2																																																																																																																																																																																																																																																																																																		
H4193	001	0	1	01	01	H4193_001_0	6	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2	2	1				2				2				1	2																2	1				2				2				1	2
H4203	001	0	1	20	08	H4203_001_0	2																																																																																																																																																																																																																																																																																																		
H4203	002	0	1	20	08	H4203_002_0	2																																																																																																																																																																																																																																																																																																		
H4213	017	1	1	09	04	H4213_017_1	5	2				2				1	40.00	40.00	40.00	2				1	2	3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1					2					2		2	2	1	3		1	20	20	20	2																					2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2						2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2																																																			2	1				1	20	20	20	2																																			
H4213	017	5	1	09	04	H4213_017_5	5	2				2				1	40.00	40.00	40.00	2				1	2	3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1					2					2		2	2	1	3		1	20	20	20	2																					2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2						2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2																																																			2	1				1	20	20	20	2																																			
H4213	017	6	1	09	04	H4213_017_6	5	2				2				1	40.00	40.00	40.00	2				1	2	3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1					2					2		2	2	1	3		1	20	20	20	2																					2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2						2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2																																																			2	1				1	20	20	20	2																																			
H4213	019	0	1	09	04	H4213_019_0	3	2				2				1	40.00	40.00	40.00	2				1	2	3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00																		2	2	2	3		2				1	0.00	0.00	0.00																																	1	1					2					2		2	2	1	3		1	20	20	20	2																					2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2						2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2																																																			2	1				1	20	20	20	2																																			
H4213	801	0	1	09	04	H4213_801_0	2	2				3		20	20	2				2																																																																																																																																																																																																																																																																																					
H4213	802	0	1	09	04	H4213_802_0	2	2				3		20	20	2				2																																																																																																																																																																																																																																																																																					
H4213	803	0	1	09	04	H4213_803_0	2	2				3		20	20	2				2																																																																																																																																																																																																																																																																																					
H4213	804	0	1	09	04	H4213_804_0	2	2				3		20	20	2				2																																																																																																																																																																																																																																																																																					
H4227	001	0	1	01	01	H4227_001_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		4250.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H4227	002	0	1	01	01	H4227_002_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		5750.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H4232	001	0	1	01	01	H4232_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4232	003	0	1	01	01	H4232_003_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4235	001	0	1	20	08	H4235_001_0	2																																																																																																																																																																																																																																																																																																		
H4235	002	0	1	20	08	H4235_002_0	2																																																																																																																																																																																																																																																																																																		
H4256	001	0	1	20	08	H4256_001_0	2																																																																																																																																																																																																																																																																																																		
H4256	002	0	1	20	08	H4256_002_0	2																																																																																																																																																																																																																																																																																																		
H4279	001	0	1	01	01	H4279_001_0	17	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		8250.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H4279	004	0	1	01	01	H4279_004_0	18	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		5000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H4286	001	0	1	01	01	H4286_001_0	6	2				2				2				2		1	1	1		7250.00	3		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1					2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4286	002	0	1	01	01	H4286_002_0	6	2				2				2				2		1	1	1		5050.00	3		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1					2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4286	003	0	1	01	01	H4286_003_0	6	2				2				2				2		1	1	1		5250.00	3		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1					2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4286	005	0	1	01	01	H4286_005_0	6	2				2				2				2		1	1	1		5050.00	3		2				2					2					2		2	2	1	4		2				2				1	1	2	2	1	4		2				2				1	1	2	1				2				2				1	1	2	2	1	4		2				2				1	1	2	2	1	3		2				2				1	1	2	1				2				2				1	1	1	1					2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	2	2	3		2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H4305	001	0	1	20	08	H4305_001_0	2																																																																																																																																																																																																																																																																																																		
H4305	002	0	1	20	08	H4305_002_0	2																																																																																																																																																																																																																																																																																																		
H4326	001	0	1	20	08	H4326_001_0	2																																																																																																																																																																																																																																																																																																		
H4326	002	0	1	20	08	H4326_002_0	2																																																																																																																																																																																																																																																																																																		
H4329	001	0	1	01	01	H4329_001_0	3	2				1	20	20	20	2				2		1	2	1		500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4346	001	0	1	02	01	H4346_001_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1800.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4346	005	0	1	02	01	H4346_005_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	006	0	1	02	01	H4346_006_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	010	0	1	01	01	H4346_010_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	012	0	1	01	01	H4346_012_0	7	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H4346	014	0	1	01	01	H4346_014_0	7	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Restorative: Fillings - 1 per tooth every 3 yearsRestorative Crowns - 1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodontal Root Planing and Scaling - 1 per quadrant every 2 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures) - 1 set every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4346	017	0	1	02	01	H4346_017_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4346	025	0	1	01	01	H4346_025_0	6	2				1	20	20	20	2				2		1	2	1		2250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	030	0	1	02	01	H4346_030_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	031	0	1	01	01	H4346_031_0	6	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4346	805	0	1	01	01	H4346_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	806	0	2	01	01	H4346_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	809	0	1	01	01	H4346_809_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	810	0	2	01	01	H4346_810_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	812	0	1	01	01	H4346_812_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	821	0	2	01	01	H4346_821_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	823	0	1	01	01	H4346_823_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	824	0	1	01	01	H4346_824_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	826	0	1	01	01	H4346_826_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	827	0	2	01	01	H4346_827_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	828	0	2	01	01	H4346_828_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4346	830	0	2	01	01	H4346_830_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4348	001	0	1	04	01	H4348_001_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4348	002	0	1	04	01	H4348_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4348	003	0	1	04	01	H4348_003_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4348	004	0	1	04	01	H4348_004_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4348	005	0	1	04	01	H4348_005_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4348	006	0	1	04	01	H4348_006_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4348	007	0	1	04	01	H4348_007_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4371	001	0	1	01	01	H4371_001_0	9	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4393	001	0	1	20	08	H4393_001_0	2																																																																																																																																																																																																																																																																																																		
H4393	002	0	1	20	08	H4393_002_0	2																																																																																																																																																																																																																																																																																																		
H4402	001	0	1	20	08	H4402_001_0	2																																																																																																																																																																																																																																																																																																		
H4402	002	0	1	20	08	H4402_002_0	2																																																																																																																																																																																																																																																																																																		
H4407	004	0	1	01	01	H4407_004_0	5	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	011	0	1	01	01	H4407_011_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		1800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	027	0	1	01	01	H4407_027_0	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2050.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	029	0	1	01	01	H4407_029_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	030	1	1	01	01	H4407_030_1	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	030	2	1	01	01	H4407_030_2	5	2				2				2				2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	030	3	1	01	01	H4407_030_3	5	2				2				1	15.00	15.00	15.00	2		1	2	1		1900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	033	0	1	01	01	H4407_033_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		1100.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	034	0	1	01	01	H4407_034_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4407	035	0	1	01	01	H4407_035_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		1800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4439	001	0	1	01	01	H4439_001_0	4	2				1	20	20	20	2				2		2	2	1		5000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4439	002	0	1	01	01	H4439_002_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4439	003	0	1	01	01	H4439_003_0	4	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4444	001	0	1	01	01	H4444_001_0	6	2				1	20	20	20	2				2		2	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4444	002	0	1	01	01	H4444_002_0	8	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4444	003	0	1	01	01	H4444_003_0	7	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H4461	004	0	1	01	01	H4461_004_0	1	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	022	0	1	01	01	H4461_022_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	025	0	1	01	01	H4461_025_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	035	0	1	01	01	H4461_035_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	038	0	1	01	01	H4461_038_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H4461	039	0	1	01	01	H4461_039_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	040	0	1	01	01	H4461_040_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		5000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	041	0	1	01	01	H4461_041_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	042	0	1	01	01	H4461_042_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	043	1	1	01	01	H4461_043_1	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	043	2	1	01	01	H4461_043_2	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	044	0	1	02	01	H4461_044_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	045	0	1	01	01	H4461_045_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	046	0	1	01	01	H4461_046_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	047	0	1	02	01	H4461_047_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	048	0	1	02	01	H4461_048_0	2	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	049	0	1	01	01	H4461_049_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	050	0	1	01	01	H4461_050_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	051	0	1	01	01	H4461_051_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	052	0	1	01	01	H4461_052_0	2	2				2				1	15.00	15.00	15.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	053	0	1	01	01	H4461_053_0	2	2				2				1	15.00	15.00	15.00	2		1	1	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	054	0	1	01	01	H4461_054_0	2	2				2				1	20.00	20.00	20.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	055	0	1	01	01	H4461_055_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	056	0	1	01	01	H4461_056_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	057	0	1	01	01	H4461_057_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	058	0	1	01	01	H4461_058_0	2	2				2				1	15.00	15.00	15.00	2		1	1	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	059	0	1	01	01	H4461_059_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	060	0	1	01	01	H4461_060_0	2	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	061	0	1	01	01	H4461_061_0	2	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	062	0	1	01	01	H4461_062_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	063	0	1	01	01	H4461_063_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	064	0	1	01	01	H4461_064_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	065	0	1	01	01	H4461_065_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4461	066	0	1	01	01	H4461_066_0	4	2				2				1	10.00	10.00	10.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	067	0	1	01	01	H4461_067_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	068	0	1	01	01	H4461_068_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	069	0	1	01	01	H4461_069_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	070	0	1	01	01	H4461_070_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	071	0	1	01	01	H4461_071_0	5	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	072	0	1	01	01	H4461_072_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H4461	073	0	1	01	01	H4461_073_0	3	2				2				1	5.00	5.00	5.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	074	0	1	01	01	H4461_074_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	075	0	1	01	01	H4461_075_0	1	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4461	076	0	1	01	01	H4461_076_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	077	0	1	01	01	H4461_077_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1250.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	078	0	1	01	01	H4461_078_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	079	0	1	01	01	H4461_079_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4461	806	0	1	01	01	H4461_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4461	807	0	1	01	01	H4461_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4461	810	0	1	01	01	H4461_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4461	811	0	1	01	01	H4461_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4471	005	0	1	01	01	H4471_005_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4471	010	1	1	01	01	H4471_010_1	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4471	010	2	1	01	01	H4471_010_2	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4471	011	0	1	01	01	H4471_011_0	6	2				1	20	20	20	2				2		1	2	1		1400.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4473	001	0	1	04	01	H4473_001_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4473	002	0	1	04	01	H4473_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4473	003	0	1	04	01	H4473_003_0	7	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4473	004	0	1	04	01	H4473_004_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4473	007	0	1	04	01	H4473_007_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H4490	001	0	1	01	01	H4490_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4490	003	0	1	01	01	H4490_003_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4497	001	1	1	04	01	H4497_001_1	15	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H4497	001	3	1	04	01	H4497_001_3	15	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H4497	002	1	1	04	01	H4497_002_1	15	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H4497	002	3	1	04	01	H4497_002_3	15	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H4497	003	1	1	04	01	H4497_003_1	14	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	30	30	30	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																																													2	1				1	30	30	30	2				2	2																2	1				1	30	30	30	2				2	2
H4497	003	3	1	04	01	H4497_003_3	14	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	30	30	30	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																																																													2	1				1	30	30	30	2				2	2																2	1				1	30	30	30	2				2	2
H4497	005	3	1	04	01	H4497_005_3	14	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H4497	005	4	1	04	01	H4497_005_4	14	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H4497	801	0	1	04	01	H4497_801_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4497	802	0	1	04	01	H4497_802_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4497	803	0	1	04	01	H4497_803_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4499	001	0	1	01	01	H4499_001_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	6	2 of periodic oral or compehensive evaluation every 12 months1 comprehensive evluation per provider/location per 36 months3 of  limited or evaluation every 12 months	2				2				2	2	2	2	1	6	Please see notes section for description of x-ray coverage	2				2				2	2																2	2	2	6	2 visits/12 months	2				2				2	2	2	2	2	6	2 fluoride treatments per 12 months	2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																																														2	1				2				2				1	2																2	1				2				2				1	2
H4506	003	0	1	02	01	H4506_003_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4506	010	0	1	02	01	H4506_010_0	8	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4506	030	0	1	02	01	H4506_030_0	6	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4513	009	0	1	01	01	H4513_009_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	026	0	1	01	01	H4513_026_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		1850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	027	0	1	01	01	H4513_027_0	4	2				2				2				2		1	2	1		3050.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	030	0	1	01	01	H4513_030_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	033	0	1	01	01	H4513_033_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	034	0	1	01	01	H4513_034_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	035	0	1	01	01	H4513_035_0	5	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	036	0	1	02	01	H4513_036_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	037	0	1	01	01	H4513_037_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	038	0	1	01	01	H4513_038_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	039	0	1	01	01	H4513_039_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	045	0	1	01	01	H4513_045_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	046	1	1	01	01	H4513_046_1	5	2				2				1	35.00	35.00	35.00	2		1	2	1		800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	046	2	1	01	01	H4513_046_2	5	2				2				1	40.00	40.00	40.00	2		1	2	1		900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	1	1	01	01	H4513_049_1	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	2	1	01	01	H4513_049_2	5	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	3	1	01	01	H4513_049_3	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	4	1	01	01	H4513_049_4	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	049	5	1	01	01	H4513_049_5	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	050	0	1	01	01	H4513_050_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	052	0	1	01	01	H4513_052_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	053	0	1	01	01	H4513_053_0	5	2				2				2				2		1	2	1		1650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	055	0	1	01	01	H4513_055_0	5	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	1	1	01	01	H4513_060_1	4	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	2	1	01	01	H4513_060_2	4	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	3	1	01	01	H4513_060_3	4	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	4	1	01	01	H4513_060_4	4	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	060	5	1	01	01	H4513_060_5	4	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	1	1	01	01	H4513_061_1	4	2				2				1	20.00	20.00	20.00	2		1	2	1		2550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	2	1	01	01	H4513_061_2	4	2				2				1	15.00	15.00	15.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	3	1	01	01	H4513_061_3	4	2				2				1	15.00	15.00	15.00	2		1	2	1		2700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	4	1	01	01	H4513_061_4	4	2				2				1	15.00	15.00	15.00	2		1	2	1		3750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	061	5	1	01	01	H4513_061_5	4	2				2				1	15.00	15.00	15.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	063	0	1	01	01	H4513_063_0	5	2				2				2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	064	0	1	01	01	H4513_064_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	068	1	1	01	01	H4513_068_1	5	2				2				1	45.00	45.00	45.00	2		1	2	1		1300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	068	2	1	01	01	H4513_068_2	5	2				2				1	35.00	35.00	35.00	2		1	2	1		800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	068	3	1	01	01	H4513_068_3	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1100.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	073	0	1	01	01	H4513_073_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	074	0	1	01	01	H4513_074_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		3100.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	075	0	1	01	01	H4513_075_0	4	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	1	1	01	01	H4513_077_1	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	2	1	01	01	H4513_077_2	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	3	1	01	01	H4513_077_3	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	077	4	1	01	01	H4513_077_4	5	2				2				1	15.00	15.00	15.00	2		1	2	1		2150.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	078	0	1	01	01	H4513_078_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	079	0	1	01	01	H4513_079_0	5	2				1	20	20	20	2				2		1	2	1		3300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	080	0	1	01	01	H4513_080_0	5	2				2				2				2		1	2	1		2350.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	081	0	1	01	01	H4513_081_0	5	2				1	20	20	20	2				2		1	2	1		3200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	1	1	01	01	H4513_083_1	4	2				2				1	45.00	45.00	45.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	083	2	1	01	01	H4513_083_2	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	3	1	01	01	H4513_083_3	4	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	4	1	01	01	H4513_083_4	4	2				2				1	35.00	35.00	35.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	083	5	1	01	01	H4513_083_5	4	2				2				1	50.00	50.00	50.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	083	6	1	01	01	H4513_083_6	4	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	083	7	1	01	01	H4513_083_7	4	2				2				1	45.00	45.00	45.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	084	0	1	02	01	H4513_084_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	085	0	1	01	01	H4513_085_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	086	0	1	01	01	H4513_086_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	087	1	1	01	01	H4513_087_1	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	087	2	1	01	01	H4513_087_2	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	087	3	1	01	01	H4513_087_3	5	2				2				1	10.00	10.00	10.00	2		1	2	1		2950.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	087	4	1	01	01	H4513_087_4	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	088	0	1	01	01	H4513_088_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	089	0	1	01	01	H4513_089_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	090	0	1	01	01	H4513_090_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		950.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	091	0	1	01	01	H4513_091_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H4513	092	0	1	01	01	H4513_092_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	093	0	1	01	01	H4513_093_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	094	0	1	01	01	H4513_094_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	095	0	1	01	01	H4513_095_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	096	0	1	02	01	H4513_096_0	4	2				2				2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	097	0	1	01	01	H4513_097_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	098	0	1	01	01	H4513_098_0	4	2				2				1	10.00	10.00	10.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4513	804	0	1	01	01	H4513_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4513	815	0	1	01	01	H4513_815_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4513	817	0	1	01	01	H4513_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4513	819	0	1	01	01	H4513_819_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4513	821	0	1	01	01	H4513_821_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4514	007	0	1	02	01	H4514_007_0	4	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H4514	014	0	1	02	01	H4514_014_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4514	015	0	1	02	01	H4514_015_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4514	016	0	1	02	01	H4514_016_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4514	017	0	1	02	01	H4514_017_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4514	018	0	1	02	01	H4514_018_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4514	021	0	1	02	01	H4514_021_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4514	022	0	1	02	01	H4514_022_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4514	023	0	1	02	01	H4514_023_0	4	2				1	20	20	20	2				2		1	1	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4514	024	0	1	02	01	H4514_024_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4514	801	0	1	01	01	H4514_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4514	803	0	1	01	01	H4514_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4514	806	0	1	01	01	H4514_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4517	001	0	1	20	08	H4517_001_0	2																																																																																																																																																																																																																																																																																																		
H4517	002	0	1	20	08	H4517_002_0	2																																																																																																																																																																																																																																																																																																		
H4518	001	0	1	20	08	H4518_001_0	2																																																																																																																																																																																																																																																																																																		
H4518	002	0	1	20	08	H4518_002_0	2																																																																																																																																																																																																																																																																																																		
H4523	001	0	1	01	01	H4523_001_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	015	0	1	01	01	H4523_015_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	020	0	1	01	01	H4523_020_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	021	0	1	01	01	H4523_021_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	024	0	1	01	01	H4523_024_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	027	0	1	01	01	H4523_027_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	028	0	1	01	01	H4523_028_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	029	0	1	01	01	H4523_029_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	030	0	1	01	01	H4523_030_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	031	0	1	01	01	H4523_031_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	034	0	1	01	01	H4523_034_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	037	0	1	01	01	H4523_037_0	3	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	038	0	1	01	01	H4523_038_0	3	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	039	0	1	01	01	H4523_039_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	041	0	1	01	01	H4523_041_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	042	0	1	01	01	H4523_042_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4523	043	0	1	01	01	H4523_043_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	044	0	1	01	01	H4523_044_0	3	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4523	801	0	1	01	01	H4523_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4523	802	0	1	01	01	H4523_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4527	001	0	1	02	01	H4527_001_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	002	0	1	02	01	H4527_002_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	003	0	1	02	01	H4527_003_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	005	0	1	02	01	H4527_005_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	013	0	1	02	01	H4527_013_0	4	2				1	20	20	20	2				2		1	1	1		1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	015	0	1	02	01	H4527_015_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4527	024	0	1	02	01	H4527_024_0	3	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	037	0	1	02	01	H4527_037_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	039	0	1	02	01	H4527_039_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	040	0	1	02	01	H4527_040_0	4	2				1	20	20	20	2				2		1	1	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	041	0	1	02	01	H4527_041_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	042	0	1	02	01	H4527_042_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	045	0	1	02	01	H4527_045_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	048	0	1	02	01	H4527_048_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	051	0	1	02	01	H4527_051_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	052	0	1	02	01	H4527_052_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	053	0	1	02	01	H4527_053_0	4	2				1	20	20	20	2				2		1	1	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4527	054	0	1	02	01	H4527_054_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4527	055	0	1	02	01	H4527_055_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	056	0	1	02	01	H4527_056_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	057	0	1	02	01	H4527_057_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4527	058	0	1	02	01	H4527_058_0	6	2				1	20	20	20	2				2		1	1	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	059	0	1	02	01	H4527_059_0	4	2				1	20	20	20	2				2		1	1	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4527	801	0	1	01	01	H4527_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4527	802	0	1	01	01	H4527_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4527	803	0	1	01	01	H4527_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H4537	001	0	1	04	01	H4537_001_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4537	004	0	1	04	01	H4537_004_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4537	005	0	1	04	01	H4537_005_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4538	003	0	1	20	08	H4538_003_0	2																																																																																																																																																																																																																																																																																																		
H4538	004	0	1	20	08	H4538_004_0	2																																																																																																																																																																																																																																																																																																		
H4544	001	0	1	04	01	H4544_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4544	002	0	1	04	01	H4544_002_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4545	001	0	1	20	08	H4545_001_0	2																																																																																																																																																																																																																																																																																																		
H4545	002	0	1	20	08	H4545_002_0	2																																																																																																																																																																																																																																																																																																		
H4604	003	0	1	02	01	H4604_003_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	005	0	1	02	01	H4604_005_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	011	0	1	02	01	H4604_011_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	012	0	1	02	01	H4604_012_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	013	0	1	02	01	H4604_013_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	014	0	1	02	01	H4604_014_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	016	0	1	02	01	H4604_016_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	017	0	1	02	01	H4604_017_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	018	0	1	02	01	H4604_018_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	019	0	1	02	01	H4604_019_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	020	0	1	02	01	H4604_020_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	022	0	1	02	01	H4604_022_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	024	0	1	02	01	H4604_024_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	025	0	1	02	01	H4604_025_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H4604	026	0	1	02	01	H4604_026_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H4604	027	0	1	02	01	H4604_027_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	028	0	1	02	01	H4604_028_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H4604	801	0	1	01	01	H4604_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4604	803	0	1	01	01	H4604_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4604	805	0	1	01	01	H4604_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4604	809	0	1	01	01	H4604_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4604	810	0	1	01	01	H4604_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4604	811	0	1	01	01	H4604_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4605	001	0	1	04	01	H4605_001_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H4605	002	0	1	04	01	H4605_002_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H4605	004	0	1	04	01	H4605_004_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H4605	801	0	1	04	01	H4605_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4605	802	0	1	04	01	H4605_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4605	803	0	1	04	01	H4605_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4605	804	0	1	04	01	H4605_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4610	001	0	1	01	01	H4610_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4610	002	0	1	01	01	H4610_002_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4623	001	0	1	02	01	H4623_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H4623	002	0	1	02	01	H4623_002_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4624	001	0	1	01	01	H4624_001_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	003	0	1	01	01	H4624_003_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	006	0	1	01	01	H4624_006_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	010	0	1	01	01	H4624_010_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	011	0	1	01	01	H4624_011_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	012	0	1	01	01	H4624_012_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	022	0	1	01	01	H4624_022_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	023	0	1	01	01	H4624_023_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	025	0	1	01	01	H4624_025_0	9	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	026	0	1	01	01	H4624_026_0	9	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																2						2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	027	0	1	01	01	H4624_027_0	10	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	028	0	1	01	01	H4624_028_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	029	0	1	01	01	H4624_029_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	031	0	1	01	01	H4624_031_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	032	0	1	01	01	H4624_032_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	033	0	1	01	01	H4624_033_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	034	0	1	01	01	H4624_034_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	036	0	1	01	01	H4624_036_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	037	0	1	01	01	H4624_037_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2400.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	038	0	1	01	01	H4624_038_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	039	0	1	01	01	H4624_039_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	040	0	1	01	01	H4624_040_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	042	0	1	01	01	H4624_042_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	043	0	1	01	01	H4624_043_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2350.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	044	0	1	01	01	H4624_044_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2150.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	045	0	1	01	01	H4624_045_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4624	046	0	1	01	01	H4624_046_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H4626	001	0	1	20	08	H4626_001_0	2																																																																																																																																																																																																																																																																																																		
H4626	002	0	1	20	08	H4626_002_0	2																																																																																																																																																																																																																																																																																																		
H4647	001	0	1	01	01	H4647_001_0	5	2				2				2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Two periapical and one set of bitewing x-rays every year.	2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		7.00	410.00	2	2	2	2	2	3		2				3		12.00	154.00	2	2	2	2	1	1		2				3		0.00	130.00	2	2	2	2	1	6	Dentures are typically covered every 5 calendar years.	2				3		16.00	656.00	2	2																															2	2	1	6	Fixed prosthodontics covered at one per tooth every 5 years.	2				3		42.00	412.00	2	2	2	2	1	6	Specified surgeries are limited to once per site per lifetime.	2				3		3.00	152.00	2	2																2	2	3	3		2				3		0.00	64.00	2	2
H4647	002	0	1	01	01	H4647_002_0	5	2				2				2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Two periapical and one set of bitewing x-rays every year.	2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		7.00	410.00	2	2	2	2	2	3		2				3		12.00	154.00	2	2	2	2	1	1		2				3		0.00	130.00	2	2	2	2	1	6	Dentures are typically covered every 5 calendar years.	2				3		16.00	656.00	2	2																															2	2	1	6	Fixed prosthodontics covered at one per tooth every 5 years.	2				3		42.00	412.00	2	2	2	2	1	6	Specified surgeries are limited to once per site per lifetime.	2				3		3.00	152.00	2	2																2	2	3	3		2				3		0.00	64.00	2	2
H4661	001	0	1	02	01	H4661_001_0	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4661	003	0	1	02	01	H4661_003_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4661	005	0	1	02	01	H4661_005_0	9	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H4676	001	0	1	01	01	H4676_001_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 of (D0210, D0330) every 3 calendar years                                                                                                               2 (D0240) every calendar year.	2				2				1	2																2	2	2	6	2 of (D1110, D4346, D4910) every calendar year,	2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below	2				2				1	2																															2	2	1	6	See notes below	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2																2	2	1	6	See notes below.	2				2				1	2
H4676	002	0	1	01	01	H4676_002_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below	2				2				1	2																2	2	2	6	See notes below.	2				2				1	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2	2	2	1	6	See notes below	2				2				1	2	2	2	1	6	See notes below	2				2				1	2																															2	2	1	6	See notes below	2				2				1	2	2	2	1	6	See notes below.	2				2				1	2																2	2	1	6	See notes below.	2				2				1	2
H4694	001	0	1	01	01	H4694_001_0	6	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4694	002	0	1	01	01	H4694_002_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4694	003	0	1	01	01	H4694_003_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4694	004	0	1	01	01	H4694_004_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4704	001	0	1	04	01	H4704_001_0	6	2				1	20	20	20	2				2		1	2	1	2	1200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4704	002	0	1	04	01	H4704_002_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H4711	001	0	1	01	01	H4711_001_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4711	002	0	1	01	01	H4711_002_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4711	005	0	1	01	01	H4711_005_0	2	2				2				1	65.00	65.00	65.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4711	008	0	1	02	01	H4711_008_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4711	010	0	1	02	01	H4711_010_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4711	011	0	1	01	01	H4711_011_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H4711	012	0	1	01	01	H4711_012_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H4711	013	0	1	01	01	H4711_013_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2																2	2	1	6	See Notes	2				1	0.00	0.00	0.00	1	2
H4711	801	0	1	01	01	H4711_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4714	001	0	1	20	08	H4714_001_0	2																																																																																																																																																																																																																																																																																																		
H4714	002	0	1	20	08	H4714_002_0	2																																																																																																																																																																																																																																																																																																		
H4733	001	0	1	01	01	H4733_001_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H4739	001	0	1	01	01	H4739_001_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		3000.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H4754	004	0	1	04	01	H4754_004_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4754	006	0	1	04	01	H4754_006_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H4754	801	0	1	04	01	H4754_801_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4754	802	0	1	04	01	H4754_802_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4808	001	0	1	04	01	H4808_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4808	002	0	1	04	01	H4808_002_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4808	003	0	1	04	01	H4808_003_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4808	004	0	1	04	01	H4808_004_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4808	005	0	1	04	01	H4808_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H4835	001	0	1	01	01	H4835_001_0	2	2				2				1	95.00	95.00	95.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4835	002	0	1	01	01	H4835_002_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4835	801	0	1	01	01	H4835_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4847	001	0	1	02	01	H4847_001_0	9	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4847	005	0	1	02	01	H4847_005_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4847	006	0	1	02	01	H4847_006_0	8	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4847	007	0	1	02	01	H4847_007_0	9	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4868	003	0	1	02	01	H4868_003_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H4868	004	0	1	01	01	H4868_004_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	every 90 days to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 1 plan year	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 3 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	date of sevice to per lifetime	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H4868	014	0	1	01	01	H4868_014_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	every 90 days to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 1 plan year	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 3 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	date of sevice to per lifetime	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H4868	016	0	1	02	01	H4868_016_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4868	019	0	1	02	01	H4868_019_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H4869	001	0	1	02	01	H4869_001_0	4	2				2				1	20.00	20.00	20.00	2		2	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2																																																													2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	5	3		2				1	0.00	0.00	0.00	1	2
H4869	003	0	1	02	01	H4869_003_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		5000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower denture per 5 years	1	50	50	50	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	011	0	1	02	01	H4869_011_0	4	2				2				1	20.00	20.00	20.00	2		2	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2	2	2	2	3		1	20	20	20	2				1	2																																																													2	2	3	3		2				1	0.00	0.00	0.00	1	2																2	2	5	3		2				1	0.00	0.00	0.00	1	2
H4869	013	0	1	02	01	H4869_013_0	5	2				2				1	15.00	15.00	15.00	2		2	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	1 upper, 1 lower denture per 5 years	1	50	50	50	2				1	2																																														2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4869	014	0	1	02	01	H4869_014_0	6	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	3	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	2	4	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																																																													2	2	3	3		2				2				1	2																2	2	5	3		2				2				1	2
H4875	016	1	1	04	01	H4875_016_1	6	2				2				3		0.00	225.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	2	1	04	01	H4875_016_2	6	2				2				3		0.00	225.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	3	1	04	01	H4875_016_3	6	2				2				3		0.00	225.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	4	1	04	01	H4875_016_4	6	2				2				3		0.00	225.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	016	5	1	04	01	H4875_016_5	6	2				2				3		0.00	225.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	018	1	1	04	01	H4875_018_1	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	018	2	1	04	01	H4875_018_2	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	018	3	1	04	01	H4875_018_3	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	018	4	1	04	01	H4875_018_4	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	018	5	1	04	01	H4875_018_5	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	2500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year.	2				2				2	2																4	2	1	6	Unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	020	1	1	04	01	H4875_020_1	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	020	2	1	04	01	H4875_020_2	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	020	3	1	04	01	H4875_020_3	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																2						2					2		3													2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	3		2				2				2	2																3													2	2
H4875	022	1	1	04	01	H4875_022_1	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	1				2				2				2	2
H4875	022	2	1	04	01	H4875_022_2	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	1				2				2				2	2
H4875	022	5	1	04	01	H4875_022_5	6	2				2				3		0.00	350.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	1				2				2				2	2
H4875	024	1	1	04	01	H4875_024_1	6	2				2				3		0.00	400.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	024	2	1	04	01	H4875_024_2	6	2				2				3		0.00	400.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																4	2	2	3		2				2				2	2	3													2	2																1	2	2	1500.00	3		2					2		4	2	1	6	Minor restorative services include fillings and crown repair. Crown repairs are covered once every 12 months. Fillings are covered once in any 2 year period, same tooth and same surface.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	4	2	1	6	Simple extractions are covered once per tooth per lifetime and brush biopsies are covered once per year	2				2				2	2																4	2	1	6	unlimited coverage for anesthesia in conjunction with qualifying dental services only.	2				2				2	2
H4875	803	0	1	04	01	H4875_803_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	804	0	1	04	01	H4875_804_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	805	0	1	04	01	H4875_805_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	806	0	1	04	01	H4875_806_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	807	0	1	04	01	H4875_807_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	808	0	1	04	01	H4875_808_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	809	0	1	04	01	H4875_809_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4875	810	0	1	04	01	H4875_810_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4882	003	0	1	04	01	H4882_003_0	8	2				2				2				2		2	2	1	2	1000.00	3		2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	2		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	009	1	1	04	01	H4882_009_1	11	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		4	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	3		0	75	2				2	2	3													2	2	4	2	2	3		3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	009	2	1	04	01	H4882_009_2	10	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		4	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	3		0	75	2				2	2	3													2	2	4	2	2	3		3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	011	1	1	04	01	H4882_011_1	9	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		4	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	3		50	75	2				2	2	3													2	2	4	2	2	3		3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	011	2	1	04	01	H4882_011_2	8	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		4	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	3		50	75	2				2	2	3													2	2	4	2	2	3		3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	014	1	1	04	01	H4882_014_1	7	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	014	2	1	04	01	H4882_014_2	6	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	1		2				2				2	2	1	1					2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H4882	801	0	1	04	01	H4882_801_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4882	803	0	1	04	01	H4882_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4882	804	0	1	04	01	H4882_804_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4882	805	0	1	04	01	H4882_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4882	806	0	1	04	01	H4882_806_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4909	014	0	1	04	01	H4909_014_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	020	0	1	04	01	H4909_020_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	021	0	1	04	01	H4909_021_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	023	0	1	04	01	H4909_023_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	026	0	1	04	01	H4909_026_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H4909	804	0	1	04	01	H4909_804_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	805	0	1	04	01	H4909_805_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	810	0	2	04	01	H4909_810_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	811	0	1	04	01	H4909_811_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	812	0	1	04	01	H4909_812_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	814	0	2	04	01	H4909_814_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	815	0	2	04	01	H4909_815_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	817	0	1	04	01	H4909_817_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4909	818	0	1	04	01	H4909_818_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4919	001	0	1	20	08	H4919_001_0	2																																																																																																																																																																																																																																																																																																		
H4919	002	0	1	20	08	H4919_002_0	2																																																																																																																																																																																																																																																																																																		
H4931	007	0	1	01	01	H4931_007_0	7	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 of 2 or 4 image or intraoral tomosynthesis bitewing per 12 mo1 intraoral comp series, tomosynthesis radiographic, panoramic per 36 mo1 intraoral tomosynthesis-periapical radiographic image per 12 mo	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings-one per tooth per 36 monthsCrowns, post, core, pins-one per tooth per 60 monthsRecement/rebond crowns- after 6 months of initial placement	2				2				2	2	2	2	1	6	1 per tooth per lifetime for pulpotomy or root canals.	2				2				2	2	2	2	1	6	Osseous surgery-1 per 24 months per quadrantPeriodontal scaling and root planing-1 per 24 months per quadrantFull mouth debridement-1 per 36 monthsPeriodontal Maintenance-1 every 3 months	2				2				2	2	2	2	1	6	1 of Removable complete, partial or immediate dentures per 60 monthsAdjustments after 6 months of placementRebase and relines every 36 months after 6 months of placement	2				2				2	2																															2	2	1	6	Fixed dentures (bridges)-1 every 60 months per toothRecement fixed partial dentures after 6 months of placement	2				2				2	2	2	2	1	6	Extractions-1 per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H4931	015	0	1	01	01	H4931_015_0	7	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 of 2 or 4 image or intraoral tomosynthesis bitewing per 12 mo1 intraoral comp series, tomosynthesis radiographic, panoramic per 36 mo1 intraoral tomosynthesis-periapical radiographic image per 12 mo	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings-one per tooth per 36 monthsCrowns, post, core, pins-one per tooth per 60 monthsRecement/rebond crowns- after 6 months of initial placement	2				2				2	2	2	2	1	6	1 per tooth per lifetime for pulpotomy or root canals.	2				2				2	2	2	2	1	6	Osseous surgery-1 per 24 months per quadrantPeriodontal scaling and root planing-1 per 24 months per quadrantFull mouth debridement-1 per 36 monthsPeriodontal Maintenance-1 every 3 months	2				2				2	2	2	2	1	6	1 of Removable complete, partial or immediate dentures per 60 monthsAdjustments after 6 months of placementRebase and relines every 36 months after 6 months of placement	2				2				2	2																															2	2	1	6	Fixed dentures (bridges)-1 every 60 months per toothRecement fixed partial dentures after 6 months of placement	2				2				2	2	2	2	1	6	Extractions-1 per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H4937	801	0	1	04	01	H4937_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4937	802	0	1	04	01	H4937_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4937	803	0	1	04	01	H4937_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4937	804	0	1	04	01	H4937_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4937	805	0	1	04	01	H4937_805_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4937	806	0	2	04	01	H4937_806_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4937	807	0	2	04	01	H4937_807_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H4939	001	0	1	02	01	H4939_001_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4939	002	0	1	02	01	H4939_002_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4939	003	0	1	02	01	H4939_003_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H4961	001	0	1	04	01	H4961_001_0	7	2				2				2				2		1	1																																																																																																																																																																																																																																																																																		
H4961	003	0	1	04	01	H4961_003_0	7	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H4961	006	0	1	04	01	H4961_006_0	8	2				2				2				2		1	2	2					2				2					2					2		4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																																																																																																																																																																																		
H4961	801	0	1	04	01	H4961_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H4961	802	0	1	04	01	H4961_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H4961	803	0	1	04	01	H4961_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H4961	804	0	1	04	01	H4961_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H4982	001	0	1	01	01	H4982_001_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	002	0	1	01	01	H4982_002_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	003	0	1	01	01	H4982_003_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	004	0	1	01	01	H4982_004_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	007	0	1	01	01	H4982_007_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		400.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	022	0	1	02	01	H4982_022_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	025	0	1	02	01	H4982_025_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	026	0	1	02	01	H4982_026_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	030	0	1	02	01	H4982_030_0	2	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H4982	801	0	1	01	01	H4982_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H4999	001	0	1	20	08	H4999_001_0	2																																																																																																																																																																																																																																																																																																		
H4999	002	0	1	20	08	H4999_002_0	2																																																																																																																																																																																																																																																																																																		
H5007	001	0	1	20	08	H5007_001_0	2																																																																																																																																																																																																																																																																																																		
H5007	002	0	1	20	08	H5007_002_0	2																																																																																																																																																																																																																																																																																																		
H5008	002	0	1	02	01	H5008_002_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5008	010	0	1	02	01	H5008_010_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5008	011	0	1	02	01	H5008_011_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5008	015	0	1	02	01	H5008_015_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5008	016	0	1	02	01	H5008_016_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5008	017	0	1	02	01	H5008_017_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5008	018	0	1	02	01	H5008_018_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5008	019	0	1	02	01	H5008_019_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5008	020	0	1	02	01	H5008_020_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5009	002	0	1	04	01	H5009_002_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H5009	011	1	1	04	01	H5009_011_1	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H5009	011	2	1	04	01	H5009_011_2	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H5009	801	0	1	04	01	H5009_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5009	802	0	1	04	01	H5009_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5009	803	0	1	04	01	H5009_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5009	804	0	1	04	01	H5009_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5015	001	0	1	01	01	H5015_001_0	5	2				1	20	20	20	2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5015	002	0	1	01	01	H5015_002_0	5	2				1	20	20	20	2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5037	001	0	1	20	08	H5037_001_0	3																																																																																																																																																																																																																																																																																																		
H5037	002	0	1	20	08	H5037_002_0	3																																																																																																																																																																																																																																																																																																		
H5042	801	0	1	04	01	H5042_801_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5042	802	0	1	04	01	H5042_802_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5042	803	0	1	04	01	H5042_803_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5050	001	0	1	01	01	H5050_001_0	3	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	004	0	1	01	01	H5050_004_0	4	2				2				1	0.00	0.00	0.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	009	0	1	01	01	H5050_009_0	4	2				2				1	25.00	25.00	25.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	017	0	1	01	01	H5050_017_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	019	0	1	01	01	H5050_019_0	4	2				2				1	20.00	20.00	20.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	021	0	1	01	01	H5050_021_0	4	2				2				1	25.00	25.00	25.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	022	0	1	01	01	H5050_022_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	023	0	1	01	01	H5050_023_0	4	2				2				1	50.00	50.00	50.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	024	0	1	01	01	H5050_024_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	025	0	1	01	01	H5050_025_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	026	0	1	01	01	H5050_026_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	027	0	1	01	01	H5050_027_0	4	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	028	0	1	01	01	H5050_028_0	4	2				2				1	50.00	50.00	50.00	2		1	1																																																																																																																																																																																																																																																																																		
H5050	029	0	1	01	01	H5050_029_0	4	2				2				1	50.00	50.00	50.00	2		1	1																																																																																																																																																																																																																																																																																		
H5050	030	0	1	01	01	H5050_030_0	4	2				2				1	50.00	50.00	50.00	2		1	1																																																																																																																																																																																																																																																																																		
H5050	031	0	1	01	01	H5050_031_0	4	2				2				1	50.00	50.00	50.00	2		1	1																																																																																																																																																																																																																																																																																		
H5050	032	0	1	01	01	H5050_032_0	4	2				2				1	50.00	50.00	50.00	2		1	1	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	2	2
H5050	801	0	1	01	01	H5050_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5050	802	0	1	01	01	H5050_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5080	001	0	1	20	08	H5080_001_0	2																																																																																																																																																																																																																																																																																																		
H5080	002	0	1	20	08	H5080_002_0	2																																																																																																																																																																																																																																																																																																		
H5085	003	0	1	20	08	H5085_003_0	2																																																																																																																																																																																																																																																																																																		
H5085	004	0	1	20	08	H5085_004_0	2																																																																																																																																																																																																																																																																																																		
H5087	005	0	1	01	01	H5087_005_0	8	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2						2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every calendar year to every 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every year to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	every calendar year	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every day to every 5 calendar years	2				1	0.00	0.00	0.00	1	2
H5087	032	0	1	01	01	H5087_032_0	8	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2						2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every calendar year to every 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every year to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	every calendar year	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every day to every 5 calendar years	2				1	0.00	0.00	0.00	1	2
H5087	034	1	1	01	01	H5087_034_1	8	2				2				1	5.00	5.00	5.00	2		1	2	2					2				2					2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2						2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every calendar year to every 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every year to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	every calendar year	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every day to every 5 calendar years	2				1	0.00	0.00	0.00	1	2
H5087	034	2	1	01	01	H5087_034_2	8	2				2				1	5.00	5.00	5.00	2		1	2	2					2				2					2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2																2						2					2		2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	2	6	every calendar year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Every calendar year to every 3 calendar years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every year to every 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	every calendar year	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every day to every 5 calendar years	2				1	0.00	0.00	0.00	1	2
H5106	029	1	1	04	01	H5106_029_1	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		3		0	10	2				2	2
H5106	029	2	1	04	01	H5106_029_2	6	2				2				1	20.00	20.00	20.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		3		0	10	2				2	2
H5106	029	3	1	04	01	H5106_029_3	6	2				2				1	25.00	25.00	25.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	10	10	10	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	10	10	10	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	10	10	10	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	10	10	10	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	10	10	10	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	10	10	10	2				2	2																2	2	2	3		3		0	10	2				2	2
H5106	030	1	1	04	01	H5106_030_1	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H5106	030	2	1	04	01	H5106_030_2	6	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H5106	030	3	1	04	01	H5106_030_3	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	20	20	20	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	20	20	20	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	20	20	20	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	20	20	20	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	20	20	20	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	20	20	20	2				2	2																2	2	2	3		3		0	20	2				2	2
H5106	034	1	1	04	01	H5106_034_1	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H5106	034	2	1	04	01	H5106_034_2	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	110100	15.00	15.00	15.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2																2	2	2	3		2								2	2																															2						2					2																																																																																																																																									2	2	2	3		2				2				2	2
H5106	035	0	1	04	01	H5106_035_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H5106	036	0	1	04	01	H5106_036_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H5106	037	0	1	04	01	H5106_037_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H5106	038	0	1	04	01	H5106_038_0	4	2				2				1	10.00	10.00	10.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		2				2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	2				2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	2				2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	2				2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	2				2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	2				2				2	2																2	2	2	3		2				2				2	2
H5106	806	0	1	04	01	H5106_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5106	807	0	1	04	01	H5106_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5106	808	0	1	04	01	H5106_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5106	810	0	1	04	01	H5106_810_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5117	801	0	1	01	01	H5117_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5119	001	0	1	01	01	H5119_001_0	6	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5124	001	0	1	20	08	H5124_001_0	2																																																																																																																																																																																																																																																																																																		
H5124	002	0	1	20	08	H5124_002_0	2																																																																																																																																																																																																																																																																																																		
H5141	004	0	1	04	01	H5141_004_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	007	0	1	04	01	H5141_007_0	6	2				2				1	2.00	2.00	2.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	025	0	1	04	01	H5141_025_0	5	2				2				2				2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	026	0	1	04	01	H5141_026_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	032	0	1	04	01	H5141_032_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	036	0	1	04	01	H5141_036_0	5	2				2				1	10.00	10.00	10.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	038	0	1	04	01	H5141_038_0	5	2				2				1	2.00	2.00	2.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	042	0	1	04	01	H5141_042_0	6	2				2				1	2.00	2.00	2.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	045	0	1	04	01	H5141_045_0	6	2				2				1	5.00	5.00	5.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	054	0	1	04	01	H5141_054_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	056	0	1	04	01	H5141_056_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	061	0	1	04	01	H5141_061_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	062	0	1	04	01	H5141_062_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H5141	063	0	1	04	01	H5141_063_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																			
H5141	801	0	1	04	01	H5141_801_0	2	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5163	001	0	1	01	01	H5163_001_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		22.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	58.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		0.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5163	002	0	1	01	01	H5163_002_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		22.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	58.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		0.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5163	003	0	1	01	01	H5163_003_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		22.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	58.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		0.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5163	004	0	1	01	01	H5163_004_0	7	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		22.00	530.00	2	2	2	2	1	3		2				3		22.00	535.00	2	2	2	2	2	3		2				3		0.00	435.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	1102.00	2	2	2	2	1	3		2				3		0.00	58.00	2	2	2	2	1	6	For a given tooth, fixed prosthodontics are covered, provided that the tooth was not previously treated with a fixed prosthodontic within the past five years.	2				3		0.00	1196.00	2	2	2	2	3	3		2				3		0.00	1615.00	2	2																2	2	2	3		2				3		0.00	165.00	2	2
H5167	001	0	1	20	08	H5167_001_0	3																																																																																																																																																																																																																																																																																																		
H5167	002	0	1	20	08	H5167_002_0	3																																																																																																																																																																																																																																																																																																		
H5178	002	0	1	01	01	H5178_002_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5190	801	0	1	01	01	H5190_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5209	005	1	1	01	01	H5209_005_1	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5209	005	2	1	01	01	H5209_005_2	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5209	006	1	1	01	01	H5209_006_1	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5209	006	2	1	01	01	H5209_006_2	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5211	001	0	1	02	01	H5211_001_0	9	2				2				2				2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H5211	002	0	1	02	01	H5211_002_0	10	2				2				2				2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H5211	003	0	1	02	01	H5211_003_0	9	2				2				2				2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H5211	004	0	1	02	01	H5211_004_0	11	2				2				2				2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H5211	010	0	1	01	01	H5211_010_0	11	2				2				2				2		2	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5211	012	0	1	02	01	H5211_012_0	11	2				2				2				2		2	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				2				2	2	4	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	4	1				1	50	50	50	2				2	2	4	2	2	3		2				2				2	2	4	2	1	3		1	20	20	20	2				2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				3		0	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																4	1				3		20	50	2				2	2
H5212	001	0	1	20	08	H5212_001_0	2																																																																																																																																																																																																																																																																																																		
H5212	002	0	1	20	08	H5212_002_0	2																																																																																																																																																																																																																																																																																																		
H5213	001	0	1	20	08	H5213_001_0	2																																																																																																																																																																																																																																																																																																		
H5213	002	0	1	20	08	H5213_002_0	2																																																																																																																																																																																																																																																																																																		
H5215	002	0	1	04	01	H5215_002_0	5	2				2				1	25.00	25.00	25.00	2		2	2	1	2	750.00	3		2				2					2	000000				2		4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	1				2				2				2	2	4	2	2	3		2				2				2	2	4	2	1	3		2				2				2	2	4	1				2				2				2	2	1	1					2					2		4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																4	1				1	50	50	50	2				1	2	4	1				1	50	50	50	2				1	2																4	1				1	50	50	50	2				1	2
H5215	005	0	1	04	01	H5215_005_0	5	2				2				2				2		2	2	1	2	100.00	3		2				2					1	100100	30.00	30.00	30.00	2		4	2	1	3		2								2	2	3													2	2	3													2	2	4	2	1	3		2								2	2	3													2	2	3													2	2																																																																																																																																																																			
H5215	007	0	1	04	01	H5215_007_0	5	2				1	20	20	20	2				2		2	2	1	2	3000.00	3		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	3		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5215	008	0	1	04	01	H5215_008_0	5	2				2				1	60.00	60.00	60.00	2		2	2	1	2	460.00	3		2				2					2	000000				2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2
H5215	009	0	1	04	01	H5215_009_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2				2					2	000000				2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2
H5215	010	0	1	04	01	H5215_010_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	2000.00	3		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	2	1	3		1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H5215	011	0	1	04	01	H5215_011_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1500.00	3		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	2	1	3		1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				1	50	50	50	2				1	2
H5215	012	0	1	04	01	H5215_012_0	5	2				2				1	55.00	55.00	55.00	2		2	2	1	2	515.00	3		2				2					2	000000				2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	2	1				2				2				2	2	4	1				2				2				2	2
H5215	013	0	1	04	01	H5215_013_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1	2	5000.00	3		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5215	014	0	1	04	01	H5215_014_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1	2	5000.00	3		2				2					2	000000				2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5215	806	0	1	04	01	H5215_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5215	807	0	1	04	01	H5215_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5215	808	0	1	04	01	H5215_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	001	0	1	04	01	H5216_001_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	006	0	1	04	01	H5216_006_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	011	0	1	04	01	H5216_011_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	013	0	1	04	01	H5216_013_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	014	0	1	04	01	H5216_014_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	017	0	1	04	01	H5216_017_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	019	0	1	04	01	H5216_019_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	023	0	1	04	01	H5216_023_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	027	0	1	04	01	H5216_027_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	032	0	1	04	01	H5216_032_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	034	0	1	04	01	H5216_034_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	037	0	1	04	01	H5216_037_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	039	0	1	04	01	H5216_039_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	042	0	1	04	01	H5216_042_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	043	1	1	04	01	H5216_043_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	043	5	1	04	01	H5216_043_5	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	043	6	1	04	01	H5216_043_6	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	048	0	1	04	01	H5216_048_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	053	0	1	04	01	H5216_053_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	059	0	1	04	01	H5216_059_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	062	0	1	04	01	H5216_062_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	063	0	1	04	01	H5216_063_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	064	0	1	04	01	H5216_064_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	068	0	1	04	01	H5216_068_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	070	0	1	04	01	H5216_070_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	072	0	1	04	01	H5216_072_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2																																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H5216	073	0	1	04	01	H5216_073_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	074	0	1	04	01	H5216_074_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	078	1	1	04	01	H5216_078_1	3	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	078	2	1	04	01	H5216_078_2	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	078	6	1	04	01	H5216_078_6	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	081	0	1	04	01	H5216_081_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	083	0	1	04	01	H5216_083_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	089	0	1	04	01	H5216_089_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	092	0	1	04	01	H5216_092_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	097	0	1	04	01	H5216_097_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	100	0	1	04	01	H5216_100_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	105	0	1	04	01	H5216_105_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	106	0	1	04	01	H5216_106_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	114	0	1	04	01	H5216_114_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	116	0	1	04	01	H5216_116_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	120	0	1	04	01	H5216_120_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H5216	124	0	1	04	01	H5216_124_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H5216	128	0	1	04	01	H5216_128_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	132	0	1	04	01	H5216_132_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	136	0	1	04	01	H5216_136_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	138	0	1	04	01	H5216_138_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	141	0	1	04	01	H5216_141_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	144	0	1	04	01	H5216_144_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	152	0	1	04	01	H5216_152_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	154	0	1	04	01	H5216_154_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	157	0	1	04	01	H5216_157_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	160	0	1	04	01	H5216_160_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	161	0	1	04	01	H5216_161_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	164	0	1	04	01	H5216_164_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	168	0	1	04	01	H5216_168_0	3	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	173	0	1	04	01	H5216_173_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	174	0	1	04	01	H5216_174_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	175	0	1	04	01	H5216_175_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	179	0	1	04	01	H5216_179_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	180	0	1	04	01	H5216_180_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	188	0	1	04	01	H5216_188_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	190	0	1	04	01	H5216_190_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	192	0	1	04	01	H5216_192_0	3	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	194	0	1	04	01	H5216_194_0	2	2				2				1	65.00	65.00	65.00	2		1	2	1	2	1500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	195	0	1	04	01	H5216_195_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	196	1	1	04	01	H5216_196_1	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	196	2	1	04	01	H5216_196_2	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	200	0	1	04	01	H5216_200_0	1	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	201	0	1	04	01	H5216_201_0	1	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	203	1	1	04	01	H5216_203_1	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	203	2	1	04	01	H5216_203_2	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	205	0	1	04	01	H5216_205_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	206	0	1	04	01	H5216_206_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	207	0	1	04	01	H5216_207_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	211	0	1	04	01	H5216_211_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	216	0	1	04	01	H5216_216_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	217	0	1	04	01	H5216_217_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	218	0	1	04	01	H5216_218_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	219	0	1	04	01	H5216_219_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	220	0	1	04	01	H5216_220_0	5	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	221	0	1	04	01	H5216_221_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	223	0	1	04	01	H5216_223_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	224	0	1	04	01	H5216_224_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	225	0	1	04	01	H5216_225_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	226	0	1	04	01	H5216_226_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	227	0	1	04	01	H5216_227_0	5	2				1	20	20	20	2				2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	228	0	1	04	01	H5216_228_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	229	0	1	04	01	H5216_229_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	231	0	1	04	01	H5216_231_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	234	0	1	04	01	H5216_234_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	235	0	1	04	01	H5216_235_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	236	0	1	04	01	H5216_236_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	242	0	1	04	01	H5216_242_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	243	0	1	04	01	H5216_243_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	244	0	1	04	01	H5216_244_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	246	0	1	04	01	H5216_246_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	249	0	1	04	01	H5216_249_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	251	0	1	04	01	H5216_251_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	252	0	1	04	01	H5216_252_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	253	0	1	04	01	H5216_253_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	256	0	1	04	01	H5216_256_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	257	0	1	04	01	H5216_257_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	258	0	1	04	01	H5216_258_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	261	0	1	04	01	H5216_261_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	263	0	1	04	01	H5216_263_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	264	0	1	04	01	H5216_264_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	265	0	1	04	01	H5216_265_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	266	0	1	04	01	H5216_266_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	267	0	1	04	01	H5216_267_0	5	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	268	0	1	04	01	H5216_268_0	5	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	269	0	1	04	01	H5216_269_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	271	0	1	04	01	H5216_271_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	275	0	1	04	01	H5216_275_0	3	2				2				1	65.00	65.00	65.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	277	0	1	04	01	H5216_277_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	278	1	1	04	01	H5216_278_1	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	278	3	1	04	01	H5216_278_3	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	280	1	1	04	01	H5216_280_1	3	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	280	2	1	04	01	H5216_280_2	3	2				2				1	5.00	5.00	5.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	281	0	1	04	01	H5216_281_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	283	0	1	04	01	H5216_283_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	284	0	1	04	01	H5216_284_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	285	0	1	04	01	H5216_285_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	286	0	1	04	01	H5216_286_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	287	0	1	04	01	H5216_287_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	288	0	1	04	01	H5216_288_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	289	0	1	04	01	H5216_289_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	291	0	1	04	01	H5216_291_0	5	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	292	0	1	04	01	H5216_292_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	296	0	1	04	01	H5216_296_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	298	0	1	04	01	H5216_298_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	300	0	1	04	01	H5216_300_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	302	0	1	04	01	H5216_302_0	6	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	304	0	1	04	01	H5216_304_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	305	0	1	04	01	H5216_305_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	306	0	1	04	01	H5216_306_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	307	0	1	04	01	H5216_307_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	308	0	1	04	01	H5216_308_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	309	0	1	04	01	H5216_309_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	310	0	1	04	01	H5216_310_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	311	0	1	04	01	H5216_311_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H5216	313	0	1	04	01	H5216_313_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	314	0	1	04	01	H5216_314_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	316	1	1	04	01	H5216_316_1	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	316	3	1	04	01	H5216_316_3	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	317	0	1	04	01	H5216_317_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	318	1	1	04	01	H5216_318_1	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	318	2	1	04	01	H5216_318_2	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	318	3	1	04	01	H5216_318_3	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	319	0	1	04	01	H5216_319_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	322	0	1	04	01	H5216_322_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	325	0	1	04	01	H5216_325_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	326	0	1	04	01	H5216_326_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	327	0	1	04	01	H5216_327_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	328	0	1	04	01	H5216_328_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	330	0	1	04	01	H5216_330_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	331	0	1	04	01	H5216_331_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	332	0	1	04	01	H5216_332_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	333	0	1	04	01	H5216_333_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	334	0	1	04	01	H5216_334_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	337	1	1	04	01	H5216_337_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	337	2	1	04	01	H5216_337_2	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	337	3	1	04	01	H5216_337_3	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	339	0	1	04	01	H5216_339_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	340	0	1	04	01	H5216_340_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	343	0	1	04	01	H5216_343_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	345	0	1	04	01	H5216_345_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	347	0	1	04	01	H5216_347_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	348	0	1	04	01	H5216_348_0	1	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	350	0	1	04	01	H5216_350_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	351	0	1	04	01	H5216_351_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	352	0	1	04	01	H5216_352_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	353	0	1	04	01	H5216_353_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	355	0	1	04	01	H5216_355_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	358	0	1	04	01	H5216_358_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	359	0	1	04	01	H5216_359_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	360	0	1	04	01	H5216_360_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	361	0	1	04	01	H5216_361_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	362	0	1	04	01	H5216_362_0	2	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	363	0	1	04	01	H5216_363_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	366	0	1	04	01	H5216_366_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	367	0	1	04	01	H5216_367_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	368	0	1	04	01	H5216_368_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	369	0	1	04	01	H5216_369_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	370	0	1	04	01	H5216_370_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	371	0	1	04	01	H5216_371_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	372	0	1	04	01	H5216_372_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	375	0	1	04	01	H5216_375_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	376	0	1	04	01	H5216_376_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	377	0	1	04	01	H5216_377_0	5	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	379	0	1	04	01	H5216_379_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	381	0	1	04	01	H5216_381_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	382	0	1	04	01	H5216_382_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	383	0	1	04	01	H5216_383_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	384	0	1	04	01	H5216_384_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	385	0	1	04	01	H5216_385_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	386	1	1	04	01	H5216_386_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	386	2	1	04	01	H5216_386_2	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	387	1	1	04	01	H5216_387_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	387	2	1	04	01	H5216_387_2	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	388	0	1	04	01	H5216_388_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	389	0	1	04	01	H5216_389_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	390	0	1	04	01	H5216_390_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	391	0	1	04	01	H5216_391_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	393	0	1	04	01	H5216_393_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H5216	394	0	1	04	01	H5216_394_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	395	0	1	04	01	H5216_395_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	396	0	1	04	01	H5216_396_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	399	0	1	04	01	H5216_399_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	400	0	1	04	01	H5216_400_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	401	0	1	04	01	H5216_401_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	402	0	1	04	01	H5216_402_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	403	0	1	04	01	H5216_403_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	404	0	1	04	01	H5216_404_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	405	0	1	04	01	H5216_405_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	406	0	1	04	01	H5216_406_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	407	0	1	04	01	H5216_407_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	408	0	1	04	01	H5216_408_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	409	0	1	04	01	H5216_409_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	410	0	1	04	01	H5216_410_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	411	0	1	04	01	H5216_411_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	412	0	1	04	01	H5216_412_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	413	0	1	04	01	H5216_413_0	2	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	414	0	1	04	01	H5216_414_0	4	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	416	0	1	04	01	H5216_416_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	417	0	1	04	01	H5216_417_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	420	0	1	04	01	H5216_420_0	5	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	421	0	1	04	01	H5216_421_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	423	0	1	04	01	H5216_423_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	424	0	1	04	01	H5216_424_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	425	0	1	04	01	H5216_425_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	426	0	1	04	01	H5216_426_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	427	1	1	04	01	H5216_427_1	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	427	2	1	04	01	H5216_427_2	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	427	3	1	04	01	H5216_427_3	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	427	4	1	04	01	H5216_427_4	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	427	5	1	04	01	H5216_427_5	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	428	1	1	04	01	H5216_428_1	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	428	2	1	04	01	H5216_428_2	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	428	3	1	04	01	H5216_428_3	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	428	5	1	04	01	H5216_428_5	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	429	0	1	04	01	H5216_429_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	430	0	1	04	01	H5216_430_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	431	0	1	04	01	H5216_431_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	432	0	1	04	01	H5216_432_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	433	0	1	04	01	H5216_433_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	435	1	1	04	01	H5216_435_1	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	435	2	1	04	01	H5216_435_2	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	435	3	1	04	01	H5216_435_3	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	436	1	1	04	01	H5216_436_1	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	436	2	1	04	01	H5216_436_2	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	436	3	1	04	01	H5216_436_3	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	437	1	1	04	01	H5216_437_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	437	2	1	04	01	H5216_437_2	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	441	0	1	04	01	H5216_441_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	442	0	1	04	01	H5216_442_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	443	0	1	04	01	H5216_443_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	444	0	1	04	01	H5216_444_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	446	0	1	04	01	H5216_446_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	447	0	1	04	01	H5216_447_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	448	0	1	04	01	H5216_448_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	449	0	1	04	01	H5216_449_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	450	0	1	04	01	H5216_450_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	451	0	1	04	01	H5216_451_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	452	0	1	04	01	H5216_452_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5216	453	0	1	04	01	H5216_453_0	2	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	455	0	1	04	01	H5216_455_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	456	1	1	04	01	H5216_456_1	3	2				2				1	10.00	10.00	10.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	456	2	1	04	01	H5216_456_2	3	2				2				1	10.00	10.00	10.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	457	1	1	04	01	H5216_457_1	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	457	2	1	04	01	H5216_457_2	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	459	0	1	04	01	H5216_459_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5216	461	0	1	04	01	H5216_461_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	463	0	1	04	01	H5216_463_0	3	2				2				1	55.00	55.00	55.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	464	0	1	04	01	H5216_464_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	465	0	1	04	01	H5216_465_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	2	1		2				1	25.00	25.00	25.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	466	0	1	04	01	H5216_466_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5216	467	0	1	04	01	H5216_467_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	468	0	1	04	01	H5216_468_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	469	0	1	04	01	H5216_469_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5216	470	0	1	04	01	H5216_470_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5216	805	0	1	04	01	H5216_805_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	806	0	1	04	01	H5216_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	808	0	2	04	01	H5216_808_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	809	0	2	04	01	H5216_809_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	811	0	1	04	01	H5216_811_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	812	0	1	04	01	H5216_812_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	813	0	1	04	01	H5216_813_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	814	0	1	04	01	H5216_814_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	817	0	1	04	01	H5216_817_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	818	0	1	04	01	H5216_818_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	821	0	1	04	01	H5216_821_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5216	824	0	1	04	01	H5216_824_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5232	001	0	1	04	01	H5232_001_0	18	2				1	0	0	0	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				2				2	2	2	2	1	6	Select endodontics procedures will only be eligible for retreatment every 4 years per the details in the evidence of coverage.	2				2				2	2	2	2	2	6	Scaling and root planing procedures subject to Utilization Review. Procedures are covered every 3 years. Periodontic maintenance covered 2 per year.	2				2				2	2	2	2	1	6	Denture replacement limited to every 5 years.	2				2				2	2																															2	2	1	6	Denture replacement limited to every 5 years.	2				2				2	2	2	1				2				2				2	2																2	2	1	6	Teledentistry visit (real-time synchronous encounter) with Dental provider covered twice per benefit plan year.	2				2				2	2
H5244	001	0	1	01	01	H5244_001_0	6	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1																2	1				2				2				1	1
H5244	002	0	1	01	01	H5244_002_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5244	004	0	1	01	01	H5244_004_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5244	005	0	1	01	01	H5244_005_0	7	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		210.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5244	801	0	1	01	01	H5244_801_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5244	802	0	1	01	01	H5244_802_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5244	803	0	1	01	01	H5244_803_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5244	804	0	1	01	01	H5244_804_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5253	004	0	1	02	01	H5253_004_0	8	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	007	0	1	02	01	H5253_007_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	011	0	1	02	01	H5253_011_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	021	0	1	02	01	H5253_021_0	7	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	024	0	1	02	01	H5253_024_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	030	0	1	02	01	H5253_030_0	7	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	033	0	1	02	01	H5253_033_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	034	0	1	02	01	H5253_034_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	035	0	1	02	01	H5253_035_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	036	0	1	02	01	H5253_036_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	037	0	1	02	01	H5253_037_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	038	0	1	02	01	H5253_038_0	4	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	039	0	1	02	01	H5253_039_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	040	0	1	02	01	H5253_040_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	041	0	1	02	01	H5253_041_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	047	0	1	02	01	H5253_047_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	048	0	1	02	01	H5253_048_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	051	0	1	02	01	H5253_051_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	059	0	1	01	01	H5253_059_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	062	0	1	02	01	H5253_062_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	064	0	1	02	01	H5253_064_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 2 every year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	072	0	1	02	01	H5253_072_0	7	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	079	0	1	02	01	H5253_079_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	080	0	1	02	01	H5253_080_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	081	0	1	02	01	H5253_081_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	082	0	1	02	01	H5253_082_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	084	0	1	02	01	H5253_084_0	7	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	087	0	1	02	01	H5253_087_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	088	0	1	02	01	H5253_088_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	089	0	1	02	01	H5253_089_0	7	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	097	0	1	02	01	H5253_097_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	099	0	1	02	01	H5253_099_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	100	0	1	02	01	H5253_100_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	103	0	1	02	01	H5253_103_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	104	0	1	02	01	H5253_104_0	5	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	105	0	1	02	01	H5253_105_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	108	1	1	02	01	H5253_108_1	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	108	2	1	02	01	H5253_108_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	108	3	1	02	01	H5253_108_3	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	109	1	1	02	01	H5253_109_1	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	109	2	1	02	01	H5253_109_2	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	109	4	1	02	01	H5253_109_4	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	110	0	1	02	01	H5253_110_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	111	1	1	02	01	H5253_111_1	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	111	2	1	02	01	H5253_111_2	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	112	1	1	02	01	H5253_112_1	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	112	2	1	02	01	H5253_112_2	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	113	0	1	02	01	H5253_113_0	3	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	116	0	1	02	01	H5253_116_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	117	0	1	02	01	H5253_117_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	119	0	1	02	01	H5253_119_0	4	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H5253	120	0	1	02	01	H5253_120_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	121	0	1	02	01	H5253_121_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	122	0	1	01	01	H5253_122_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	124	1	1	02	01	H5253_124_1	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	124	2	1	02	01	H5253_124_2	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	125	1	1	02	01	H5253_125_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	125	2	1	02	01	H5253_125_2	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	126	1	1	02	01	H5253_126_1	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	126	2	1	02	01	H5253_126_2	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	127	0	1	02	01	H5253_127_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	128	0	1	02	01	H5253_128_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	130	0	1	02	01	H5253_130_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	131	0	1	02	01	H5253_131_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	132	0	1	02	01	H5253_132_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	133	0	1	02	01	H5253_133_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	134	0	1	02	01	H5253_134_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	135	0	1	02	01	H5253_135_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	141	0	1	02	01	H5253_141_0	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	142	0	1	02	01	H5253_142_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	143	0	1	02	01	H5253_143_0	3	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	144	1	1	02	01	H5253_144_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	144	2	1	02	01	H5253_144_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	145	0	1	02	01	H5253_145_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	146	0	1	02	01	H5253_146_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	147	0	1	02	01	H5253_147_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	148	0	1	02	01	H5253_148_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	149	0	1	02	01	H5253_149_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	150	0	1	02	01	H5253_150_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	152	0	1	02	01	H5253_152_0	3	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	154	0	1	02	01	H5253_154_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	155	0	1	02	01	H5253_155_0	7	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	157	1	1	02	01	H5253_157_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	157	2	1	02	01	H5253_157_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	159	0	1	02	01	H5253_159_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	161	0	1	02	01	H5253_161_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	162	1	1	02	01	H5253_162_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	162	2	1	02	01	H5253_162_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	166	0	1	02	01	H5253_166_0	6	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	168	0	1	02	01	H5253_168_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	169	0	1	02	01	H5253_169_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	171	0	1	02	01	H5253_171_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	172	0	1	02	01	H5253_172_0	4	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	173	0	1	02	01	H5253_173_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	174	0	1	02	01	H5253_174_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	175	0	1	02	01	H5253_175_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	176	0	1	02	01	H5253_176_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	178	0	1	02	01	H5253_178_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	179	0	1	02	01	H5253_179_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	180	0	1	02	01	H5253_180_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	182	0	1	02	01	H5253_182_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	183	0	1	02	01	H5253_183_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	184	0	1	02	01	H5253_184_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	185	0	1	02	01	H5253_185_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	186	0	1	02	01	H5253_186_0	11	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	187	0	1	02	01	H5253_187_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	188	0	1	02	01	H5253_188_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	189	0	1	02	01	H5253_189_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	190	0	1	02	01	H5253_190_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	192	0	1	02	01	H5253_192_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	193	1	1	02	01	H5253_193_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	193	2	1	02	01	H5253_193_2	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	194	1	1	02	01	H5253_194_1	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	194	2	1	02	01	H5253_194_2	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	195	0	1	02	01	H5253_195_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	196	0	1	02	01	H5253_196_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	197	0	1	02	01	H5253_197_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	198	0	1	02	01	H5253_198_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	199	0	1	02	01	H5253_199_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	200	0	1	02	01	H5253_200_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5253	201	0	1	02	01	H5253_201_0	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	202	0	1	02	01	H5253_202_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	203	0	1	02	01	H5253_203_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	204	0	1	02	01	H5253_204_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	205	0	1	02	01	H5253_205_0	3	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	206	0	1	02	01	H5253_206_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5253	207	0	1	02	01	H5253_207_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	208	0	1	02	01	H5253_208_0	4	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		3													2	2	3													2	2	3													2	2	3													2	2	3													2	2																3													2	2	3													2	2																3													2	2
H5253	209	0	1	02	01	H5253_209_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5253	801	0	1	01	01	H5253_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	802	0	1	01	01	H5253_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	805	0	1	01	01	H5253_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	810	0	1	01	01	H5253_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	811	0	1	01	01	H5253_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	812	0	1	01	01	H5253_812_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	813	0	1	01	01	H5253_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	814	0	1	01	01	H5253_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	815	0	1	01	01	H5253_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	816	0	2	01	01	H5253_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	817	0	2	01	01	H5253_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	818	0	1	01	01	H5253_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	819	0	1	01	01	H5253_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	820	0	1	01	01	H5253_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	821	0	1	01	01	H5253_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	822	0	1	01	01	H5253_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	823	0	1	01	01	H5253_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	824	0	1	01	01	H5253_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	825	0	1	01	01	H5253_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	826	0	2	01	01	H5253_826_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	827	0	1	01	01	H5253_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	828	0	1	01	01	H5253_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	829	0	1	01	01	H5253_829_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	830	0	1	01	01	H5253_830_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	831	0	1	01	01	H5253_831_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5253	832	0	1	01	01	H5253_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5256	001	0	1	18	06	H5256_001_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5256	002	0	1	18	06	H5256_002_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5256	004	0	1	18	06	H5256_004_0	2	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5256	005	0	1	18	06	H5256_005_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5262	001	0	1	01	01	H5262_001_0	4	2				2				1	45.00	45.00	45.00	2		2	2	1		600.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	003	0	1	01	01	H5262_003_0	4	2				2				1	50.00	50.00	50.00	2		2	2	1		425.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	004	0	1	01	01	H5262_004_0	3	2				2				1	50.00	50.00	50.00	2		2	2	1		1000.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	005	0	1	01	01	H5262_005_0	3	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	007	0	1	01	01	H5262_007_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1		575.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	008	0	1	01	01	H5262_008_0	4	2				2				1	50.00	50.00	50.00	2		2	2	1		475.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	009	0	1	01	01	H5262_009_0	3	2				2				1	40.00	40.00	40.00	2		2	2	1		2000.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	010	0	1	01	01	H5262_010_0	3	2				2				1	35.00	35.00	35.00	2		2	2	1		1000.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	021	0	1	01	01	H5262_021_0	4	2				2				1	60.00	60.00	60.00	2		2	2	1		400.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	023	0	1	01	01	H5262_023_0	4	2				2				1	65.00	65.00	65.00	2		2	2	1		400.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H5262	029	0	1	01	01	H5262_029_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5262	030	0	1	01	01	H5262_030_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5262	032	0	1	01	01	H5262_032_0	4	2				2				1	75.00	75.00	75.00	2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H5262	033	0	1	01	01	H5262_033_0	4	2				2				1	75.00	75.00	75.00	2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H5262	801	0	1	01	01	H5262_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5262	802	0	1	01	01	H5262_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5264	002	0	1	18	06	H5264_002_0	2	2				2				2				2		2	2	1		300.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period.	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5264	005	0	1	18	06	H5264_005_0	2	2				2				2				2		2	2	1		300.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period.	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H5272	001	0	1	01	01	H5272_001_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5273	001	0	1	01	01	H5273_001_0	7	2				2				1	45.00	45.00	45.00	2		1	1	1		2000.00	3		2				2					2					1	100.00	2	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	2	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					1	100.00	2	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	2	2	3	6	Covers 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	2	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	1	50	50	50	2				2	2	2	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															2	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	2	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	1	50	50	50	2				2	2																2	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2
H5273	801	0	1	01	01	H5273_801_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5273	802	0	1	01	01	H5273_802_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5273	803	0	1	01	01	H5273_803_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5273	804	0	1	01	01	H5273_804_0	3	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5294	010	0	1	01	01	H5294_010_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	011	0	1	01	01	H5294_011_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5294	013	0	1	01	01	H5294_013_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5294	014	0	1	01	01	H5294_014_0	8	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	015	0	1	01	01	H5294_015_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	016	0	1	01	01	H5294_016_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5294	017	0	1	01	01	H5294_017_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5294	018	0	1	01	01	H5294_018_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5294	019	0	1	01	01	H5294_019_0	8	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5294	021	0	1	01	01	H5294_021_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	022	0	1	01	01	H5294_022_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	023	0	1	01	01	H5294_023_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	024	0	1	01	01	H5294_024_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5294	025	0	1	01	01	H5294_025_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5296	003	0	1	01	01	H5296_003_0	9	2				2				2				2		1	2	2					2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		2000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	004	0	1	02	01	H5296_004_0	6	2				2				2				2		1	2	1		2400.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	006	0	1	01	01	H5296_006_0	10	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	1	4	2	1	1		2				2				1	1																4	2	1	4		2				2				1	1	4	2	1	4		2				2				1	1																																																																																																																																																																																		
H5296	007	0	1	01	01	H5296_007_0	9	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	008	0	1	01	01	H5296_008_0	8	2				2				2				2		1	2	2					2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																													3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																														
H5296	009	0	1	02	01	H5296_009_0	6	2				2				2				2		1	2	1		2400.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	010	0	1	01	01	H5296_010_0	8	2				2				2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	011	0	1	01	01	H5296_011_0	6	2				2				2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5296	801	0	1	01	01	H5296_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5296	802	0	1	01	01	H5296_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5296	803	0	1	01	01	H5296_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5296	804	0	1	01	01	H5296_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5299	001	0	1	01	01	H5299_001_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5299	002	0	1	01	01	H5299_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5299	006	0	1	01	01	H5299_006_0	7	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	009	0	1	01	01	H5299_009_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	012	0	1	01	01	H5299_012_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5299	013	0	1	01	01	H5299_013_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	014	0	1	01	01	H5299_014_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	015	0	1	01	01	H5299_015_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	016	0	1	01	01	H5299_016_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	017	0	1	01	01	H5299_017_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5299	018	0	1	01	01	H5299_018_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5302	012	0	1	01	01	H5302_012_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5302	020	0	1	01	01	H5302_020_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5302	022	0	1	01	01	H5302_022_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5302	023	0	1	01	01	H5302_023_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5302	024	0	1	01	01	H5302_024_0	2	2				1	20	20	20	2				2		1	2	1		4500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5302	026	0	1	01	01	H5302_026_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5302	809	0	1	01	01	H5302_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5314	001	0	1	01	01	H5314_001_0	6	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5314	002	0	1	01	01	H5314_002_0	6	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5322	025	0	1	02	01	H5322_025_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	026	0	1	02	01	H5322_026_0	4	2				1	20	20	20	2				2		1	1	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5322	028	0	1	02	01	H5322_028_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	029	0	1	02	01	H5322_029_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	031	0	1	02	01	H5322_031_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	033	0	1	02	01	H5322_033_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5322	034	0	1	02	01	H5322_034_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 5 years to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per lifetime to unlimited.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 1 per year to 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for each service in this category is 2 per year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities will vary by service ranging from 2 per year to unlimited.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Periodicities will vary by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 24 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 every 96 months to unlimited.	2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service rangings from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicities will vary by service ranging from 1 per day to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	038	0	1	02	01	H5322_038_0	4	2				1	20	20	20	2				2		1	1	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5322	040	0	1	02	01	H5322_040_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5322	043	0	1	02	01	H5322_043_0	3	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5322	044	0	1	02	01	H5322_044_0	4	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H5322	046	0	1	02	01	H5322_046_0	4	2				1	20	20	20	2				2		1	1	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	047	1	1	02	01	H5322_047_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5322	047	2	1	02	01	H5322_047_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5322	049	1	1	02	01	H5322_049_1	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	049	2	1	02	01	H5322_049_2	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	050	1	1	02	01	H5322_050_1	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	050	2	1	02	01	H5322_050_2	4	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5322	801	0	1	01	01	H5322_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5322	802	0	1	01	01	H5322_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5322	803	0	1	01	01	H5322_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5322	804	0	2	01	01	H5322_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5325	003	0	1	01	01	H5325_003_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	004	0	1	01	01	H5325_004_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	005	0	1	01	01	H5325_005_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	006	0	1	01	01	H5325_006_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	007	0	1	01	01	H5325_007_0	3	2				1	20	20	20	2				2		1	2	1		1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	011	0	1	01	01	H5325_011_0	2	2				2				1	15.00	15.00	15.00	2		1	2	1		1200.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	012	0	1	01	01	H5325_012_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	013	0	1	01	01	H5325_013_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	014	0	1	01	01	H5325_014_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5325	015	0	1	01	01	H5325_015_0	2	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5361	001	0	1	04	01	H5361_001_0	9	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5361	002	0	1	04	01	H5361_002_0	7	2				2				1	15.00	15.00	15.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. I root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6 - 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7 Prosthodontics, fixed - 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5361	004	0	1	04	01	H5361_004_0	7	2				2				1	55.00	55.00	55.00	2		2	2	2					2				2					2					2		2	2	1	6	Subject to limitations described in note.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	#16b2, Dental X-rays: Includes 1 set Bitewing X-rays per year. Periapical, Panoramic, & Full Mouth X-rays 1 per 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	2	2	500.00	3		2					2		2	2	1	6	#16c1, Restorative: 1 filling per tooth every 2 years. 1 crown per tooth every 5 years.	1	20	20	20	2				2	2	2	2	1	6	#16c2, Endodontics: 1 root canal per tooth per lifetime. 1 root canal retreatment per tooth per lifetime. 1 root canal repair per tooth per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c3, Periodontics: 4 maintenance procedures every year. 1 scaling and root planing procedure every 2 years per mouth quadrant. 1 full mouth debridement per lifetime.	1	20	20	20	2				2	2	2	2	1	6	#16c4, Prosthodontics removable: 1 complete and partial set dentures every 5 years. 1 denture adjustment, reline, rebase, and repair every 2 years. 1 tissue conditioning per tooth per denture per life	1	40	40	40	2				2	2																2	2	1	6	#16c6, Implant Services: 1 implant per tooth every 5 years.	1	40	40	40	2				2	2	2	2	1	6	#16c7, Prosthodontics, fixed: 1 set bridges every 5 years.	1	40	40	40	2				2	2	2	1				3		20	40	2				2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5374	001	0	1	01	01	H5374_001_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5377	002	0	1	02	01	H5377_002_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5377	003	0	1	01	01	H5377_003_0	4	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5386	003	0	1	01	01	H5386_003_0	7	2				2				1	35.00	35.00	35.00	2		1	1																																																																																																																																																																																																																																																																																		
H5386	004	0	1	01	01	H5386_004_0	8	2				2				1	30.00	30.00	30.00	2		1	1	2					2				2					2					2		4	1				2				3		0.00	5.00	1	1	4	2	1	4		2				2				1	1	4	1				2				3		0.00	5.00	1	1	4	2	1	4		2				1	15.00	15.00	15.00	1	1																4	1				2				3		0.00	150.00	1	1	2						2					2		4	1				2				3		20.00	425.00	1	1	4	1				2				3		0.00	475.00	1	1	4	1				2				3		0.00	450.00	1	1	4	1				2				3		20.00	495.00	1	1																															4	1				2				3		30.00	425.00	1	1	4	1				2				3		0.00	65.00	1	1																4	1				2				3		0.00	50.00	1	1
H5386	005	0	1	01	01	H5386_005_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		4	1				2				3		0.00	5.00	1	1	4	2	1	4		2				2				1	1	4	1				2				3		0.00	5.00	1	1	4	2	1	4		2				1	15.00	15.00	15.00	1	1																4	1				2				3		0.00	150.00	1	1	2						2					2		4	1				2				3		20.00	425.00	1	1	4	1				2				3		0.00	475.00	1	1	4	1				2				3		0.00	450.00	1	1	4	1				2				3		20.00	495.00	1	1																															4	1				2				3		30.00	425.00	1	1	4	1				2				3		0.00	65.00	1	1																4	1				2				3		0.00	50.00	1	1
H5386	006	0	1	01	01	H5386_006_0	8	2				2				1	35.00	35.00	35.00	2		1	1	2					2				2					2					2		4	1				2				3		0.00	5.00	1	1	4	2	1	4		2				2				1	1	4	1				2				3		0.00	5.00	1	1	4	2	1	4		2				1	15.00	15.00	15.00	1	1																4	1				2				3		0.00	150.00	1	1	2						2					2		4	1				2				3		20.00	425.00	1	1	4	1				2				3		0.00	475.00	1	1	4	1				2				3		0.00	450.00	1	1	4	1				2				3		20.00	495.00	1	1																															4	1				2				3		30.00	425.00	1	1	4	1				2				3		0.00	65.00	1	1																4	1				2				3		0.00	50.00	1	1
H5386	801	0	1	01	01	H5386_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5386	802	0	1	01	01	H5386_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5386	803	0	1	01	01	H5386_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5397	001	0	1	01	01	H5397_001_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5397	002	0	1	01	01	H5397_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5397	003	0	1	01	01	H5397_003_0	6	2				1	30	30	30	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5397	004	0	1	01	01	H5397_004_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5397	005	0	1	01	01	H5397_005_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5403	001	0	1	20	08	H5403_001_0	2																																																																																																																																																																																																																																																																																																		
H5403	002	0	1	20	08	H5403_002_0	2																																																																																																																																																																																																																																																																																																		
H5405	001	0	1	20	08	H5405_001_0	4																																																																																																																																																																																																																																																																																																		
H5405	002	0	1	20	08	H5405_002_0	4																																																																																																																																																																																																																																																																																																		
H5406	001	0	1	20	08	H5406_001_0	2																																																																																																																																																																																																																																																																																																		
H5406	002	0	1	20	08	H5406_002_0	2																																																																																																																																																																																																																																																																																																		
H5410	004	0	1	01	01	H5410_004_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	013	0	1	01	01	H5410_013_0	5	2				2				2				2		1	2	1		2400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	018	0	1	01	01	H5410_018_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	024	0	1	01	01	H5410_024_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		2050.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	025	0	1	01	01	H5410_025_0	5	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	026	0	1	01	01	H5410_026_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	031	0	1	01	01	H5410_031_0	5	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	032	0	1	01	01	H5410_032_0	5	2				2				2				2		1	2	1		2350.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	042	0	1	01	01	H5410_042_0	5	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	045	0	1	01	01	H5410_045_0	5	2				1	20	20	20	2				2		1	2	1		1450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	046	0	1	01	01	H5410_046_0	5	2				1	20	20	20	2				2		1	2	1		2100.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	047	0	1	01	01	H5410_047_0	5	2				2				2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	055	0	1	01	01	H5410_055_0	5	2				2				2				2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	056	0	1	01	01	H5410_056_0	5	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	059	0	1	01	01	H5410_059_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	060	0	1	01	01	H5410_060_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5410	808	0	1	01	01	H5410_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5420	001	0	1	01	01	H5420_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H5420	003	0	1	01	01	H5420_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H5420	006	0	1	01	01	H5420_006_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H5420	014	0	1	01	01	H5420_014_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H5420	015	0	1	01	01	H5420_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	1	4		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Every 5 Years	2				1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																														
H5420	016	0	1	02	01	H5420_016_0	4	2				1	20	20	20	2				2		1	2	1		4500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H5422	011	0	1	02	01	H5422_011_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																		
H5422	013	0	1	02	01	H5422_013_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5422	014	0	1	02	01	H5422_014_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5422	015	0	1	02	01	H5422_015_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5422	018	0	1	01	01	H5422_018_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5422	019	0	1	01	01	H5422_019_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5422	803	0	1	01	01	H5422_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5422	804	0	1	01	01	H5422_804_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5422	806	0	2	01	01	H5422_806_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5422	807	0	2	01	01	H5422_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5422	809	0	1	01	01	H5422_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5422	811	0	2	01	01	H5422_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5425	001	0	1	01	01	H5425_001_0	6	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	2	2	4	1				2				3		5.00	395.00	2	2	4	1				2				3		0.00	380.00	2	2	4	1				2				3		13.00	395.00	2	2																															4	1				2				3		25.00	395.00	2	2	4	1				2				3		0.00	140.00	2	2																4	1				2				3		0.00	125.00	2	2
H5425	005	0	1	01	01	H5425_005_0	6	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	2	2	4	1				2				3		5.00	395.00	2	2	4	1				2				3		0.00	380.00	2	2	4	1				2				3		13.00	395.00	2	2																															4	1				2				3		25.00	395.00	2	2	4	1				2				3		0.00	140.00	2	2																4	1				2				3		0.00	125.00	2	2
H5425	006	0	1	01	01	H5425_006_0	8	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	007	0	1	01	01	H5425_007_0	6	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	008	0	1	01	01	H5425_008_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	009	0	1	01	01	H5425_009_0	6	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	019	0	1	01	01	H5425_019_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	034	0	1	01	01	H5425_034_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	065	0	1	01	01	H5425_065_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	069	0	1	01	01	H5425_069_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	070	0	1	01	01	H5425_070_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	075	0	1	01	01	H5425_075_0	6	2				2				2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	076	0	1	01	01	H5425_076_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	082	0	1	01	01	H5425_082_0	6	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	084	0	1	01	01	H5425_084_0	6	2				2				1	5.00	5.00	5.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	5.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	80.00	2	2	2						2					2		2	1				2				3		8.00	395.00	1	2	2	1				2				3		5.00	395.00	1	2	2	1				2				3		0.00	380.00	1	2	2	1				2				3		13.00	395.00	1	2																															2	1				2				3		25.00	395.00	1	2	2	1				2				3		0.00	140.00	1	2																2	1				2				3		0.00	125.00	1	2
H5425	085	0	1	01	01	H5425_085_0	6	2				2				1	5.00	5.00	5.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	5.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				3		0.00	80.00	2	2	2						2					2		2	1				2				3		8.00	395.00	1	2	2	1				2				3		5.00	395.00	1	2	2	1				2				3		0.00	380.00	1	2	2	1				2				3		13.00	395.00	1	2																															2	1				2				3		25.00	395.00	1	2	2	1				2				3		0.00	140.00	1	2																2	1				2				3		0.00	125.00	1	2
H5425	086	0	1	01	01	H5425_086_0	8	2				2				2				2		1	1	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	087	0	1	01	01	H5425_087_0	9	2				2				2				2		1	1	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	091	0	1	02	01	H5425_091_0	7	2				2				2				2		1	1	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	092	0	1	01	01	H5425_092_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	096	0	1	01	01	H5425_096_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	097	0	1	01	01	H5425_097_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	098	0	1	01	01	H5425_098_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	100	0	1	01	01	H5425_100_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	101	0	1	01	01	H5425_101_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	102	0	1	01	01	H5425_102_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	104	0	1	01	01	H5425_104_0	8	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	105	0	1	01	01	H5425_105_0	8	2				2				2				2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	106	0	1	01	01	H5425_106_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	107	0	1	01	01	H5425_107_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	108	0	1	01	01	H5425_108_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		240.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	109	0	1	01	01	H5425_109_0	8	2				2				2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		245.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	110	0	1	01	01	H5425_110_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		215.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	118	0	1	01	01	H5425_118_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2500.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	119	0	1	01	01	H5425_119_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		240.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	120	0	1	01	01	H5425_120_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		245.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	121	0	1	01	01	H5425_121_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		210.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	123	0	1	01	01	H5425_123_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2500.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	124	0	1	01	01	H5425_124_0	6	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	3		2				2				2	2																																																																																																									
H5425	125	0	1	01	01	H5425_125_0	6	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	3		2				2				2	2																																																																																																									
H5425	126	0	1	01	01	H5425_126_0	6	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	3		2				2				2	2																																																																																																									
H5425	127	0	1	01	01	H5425_127_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	3		2				2				2	2																																																																																																									
H5425	128	0	1	01	01	H5425_128_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	129	0	1	01	01	H5425_129_0	8	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	130	0	1	01	01	H5425_130_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		230.00	5		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5425	131	0	1	01	01	H5425_131_0	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	132	0	1	02	01	H5425_132_0	6	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	133	0	1	01	01	H5425_133_0	6	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2																																2	2	1	3		2				2				2	2																																																																																																									
H5425	134	0	1	01	01	H5425_134_0	7	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		4	2	2	3		2				2				2	2	4	2	2	3		2				2				2	2	4	1				2				3		0.00	5.00	2	2	4	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	4	1				2				3		0.00	80.00	2	2	2						2					2		4	1				2				3		8.00	395.00	1	2	4	1				2				3		5.00	395.00	1	2	4	1				2				3		0.00	380.00	1	2	4	1				2				3		13.00	395.00	1	2																															4	1				2				3		25.00	395.00	1	2	4	1				2				3		0.00	140.00	1	2																4	1				2				3		0.00	125.00	1	2
H5425	135	0	1	01	01	H5425_135_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5425	803	0	1	01	01	H5425_803_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5425	804	0	1	01	01	H5425_804_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5425	806	0	1	01	01	H5425_806_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5425	807	0	1	01	01	H5425_807_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5427	052	0	1	01	01	H5427_052_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	059	0	1	01	01	H5427_059_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	060	0	1	01	01	H5427_060_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	070	0	1	01	01	H5427_070_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	072	0	1	01	01	H5427_072_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	077	0	1	01	01	H5427_077_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	078	0	1	01	01	H5427_078_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	082	0	1	01	01	H5427_082_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	083	0	1	01	01	H5427_083_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	087	0	1	01	01	H5427_087_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	088	0	1	01	01	H5427_088_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	089	0	1	01	01	H5427_089_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	091	0	1	01	01	H5427_091_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	093	0	1	01	01	H5427_093_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	094	0	1	01	01	H5427_094_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	096	0	1	01	01	H5427_096_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	099	0	1	01	01	H5427_099_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	102	0	1	01	01	H5427_102_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	103	0	1	01	01	H5427_103_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	105	0	1	01	01	H5427_105_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	106	0	1	01	01	H5427_106_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	107	0	1	01	01	H5427_107_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	108	0	1	01	01	H5427_108_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	112	0	1	02	01	H5427_112_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5427	113	0	1	02	01	H5427_113_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5431	001	0	1	01	01	H5431_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	006	0	1	01	01	H5431_006_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	012	0	1	01	01	H5431_012_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	013	0	1	01	01	H5431_013_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	016	0	1	01	01	H5431_016_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	017	0	1	01	01	H5431_017_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	018	0	1	01	01	H5431_018_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	019	0	1	01	01	H5431_019_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	020	0	1	01	01	H5431_020_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	021	0	1	01	01	H5431_021_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	022	0	1	01	01	H5431_022_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	025	0	1	01	01	H5431_025_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5431	026	0	1	01	01	H5431_026_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	X-rays include:• Up to 2 periapical dental x-rays every year.• Up to 2 bitewing dental x-rays every year.• Up to 1 complete series of full-mouth or panoramic x-rays every 3 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	6	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	7	6	1 Scaling/root planing per each quadrant every year.1 Full mouth debridement every 24 consecutive months.2 periodontal maintenance every year.	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																2	2	2	3		2				1	0.00	0.00	0.00	1	2																2	2	4	3		2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5433	001	0	1	01	01	H5433_001_0	4	2				1	20	20	20	2				2		2	2	2					2														2		2	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																												2						2					2		2	2	1	6	Restorative Crowns - 1 per tooth every 7 calendar years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Prosthodontics - Rebases for full or partial dentures covered once every 2 calendar years. Replacement of all teeth & acrylic on cast metal frame covered once every 3 calendar years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges) - 1 per tooth every 7 calendar years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	One consultation is covered every calendar year	2				1	0.00	0.00	0.00	1	2
H5434	002	0	1	04	01	H5434_002_0	9	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	023	0	1	04	01	H5434_023_0	8	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	024	0	1	04	01	H5434_024_0	8	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	025	0	1	04	01	H5434_025_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	026	0	1	04	01	H5434_026_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	030	0	1	04	01	H5434_030_0	9	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	031	0	1	04	01	H5434_031_0	8	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	034	0	1	04	01	H5434_034_0	8	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	035	0	1	04	01	H5434_035_0	8	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	036	0	1	04	01	H5434_036_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					1	110111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	2	2	3		2								2	2	2						2					2		2	2	1	6	Fillings: 1 per year	2				1	0.00	0.00	0.00	2	2																															2	2	5	6	Partial or complete dentures (including immediate): Limited to one set (one upper and one lower) every 60 months. Adjustments: Limited to one per arch (upper and lower) per year. Repairs: Limited to one per year.Rebase or Reline: Limited to one per year.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	038	0	1	04	01	H5434_038_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	040	0	1	04	01	H5434_040_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	041	0	1	04	01	H5434_041_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	042	0	1	04	01	H5434_042_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	044	0	1	04	01	H5434_044_0	5	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	045	0	1	04	01	H5434_045_0	10	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	046	0	1	04	01	H5434_046_0	4	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					1	110100	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	Bitewing X-rays (one set) are covered once per year. A full-mouth series (intraoral complete series) or a panoramic X-ray is covered once every three years and counts toward the annual limit for 1 set per year.	2								2	2																2	2	2	3		2								2	2																															2						2					2																																															2	2	1	3		2				1	0.00	0.00	0.00	2	2																																														2	2	1	3		2				1	0.00	0.00	0.00	2	2																														
H5434	801	0	1	04	01	H5434_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5434	802	0	1	04	01	H5434_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5434	806	0	1	04	01	H5434_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5434	807	0	1	04	01	H5434_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5435	001	0	1	09	04	H5435_001_0	3	2				1	20	20	20	2				2				1		500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00			1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2																					2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2																					2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2					
H5435	024	0	1	09	04	H5435_024_0	5	2				1	20	20	20	2				2				1		500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00			2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00			1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2																					2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2						2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2																					2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2					
H5439	010	0	1	04	01	H5439_010_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2	2	2	1	6	every date of service to 5 years	1	40	40	40	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	Every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H5439	011	0	1	04	01	H5439_011_0	12	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H5439	015	0	1	04	01	H5439_015_0	9	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5439	019	0	1	04	01	H5439_019_0	10	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5439	022	1	1	04	01	H5439_022_1	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5439	022	2	1	04	01	H5439_022_2	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5439	022	3	1	04	01	H5439_022_3	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5447	001	0	1	01	01	H5447_001_0	6	2				2				1	15.00	15.00	15.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5447	002	0	1	01	01	H5447_002_0	6	2				1	20	20	20	2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5453	001	0	1	04	01	H5453_001_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	002	0	1	04	01	H5453_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	003	0	1	04	01	H5453_003_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	004	0	1	04	01	H5453_004_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	005	0	1	04	01	H5453_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	010	0	1	04	01	H5453_010_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	011	0	1	04	01	H5453_011_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5453	015	0	1	04	01	H5453_015_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	016	0	1	04	01	H5453_016_0	6	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	017	0	1	04	01	H5453_017_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5453	018	0	1	04	01	H5453_018_0	7	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5454	001	0	1	01	01	H5454_001_0	9	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H5454	002	0	1	01	01	H5454_002_0	9	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		1500.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H5454	005	0	1	01	01	H5454_005_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H5454	006	0	1	01	01	H5454_006_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H5471	064	0	1	01	01	H5471_064_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	065	0	1	01	01	H5471_065_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	066	0	1	01	01	H5471_066_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	069	0	1	01	01	H5471_069_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	070	0	1	01	01	H5471_070_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	071	0	1	01	01	H5471_071_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	072	0	1	01	01	H5471_072_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	073	0	1	01	01	H5471_073_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	074	0	1	01	01	H5471_074_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	075	0	1	01	01	H5471_075_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	076	0	1	01	01	H5471_076_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	077	0	1	01	01	H5471_077_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	078	0	1	01	01	H5471_078_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	080	0	1	01	01	H5471_080_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	082	0	1	01	01	H5471_082_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	084	0	1	01	01	H5471_084_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	110	0	1	01	01	H5471_110_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	111	0	1	01	01	H5471_111_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	112	0	1	01	01	H5471_112_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	113	0	1	01	01	H5471_113_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	114	0	1	01	01	H5471_114_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	115	0	1	01	01	H5471_115_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	116	0	1	01	01	H5471_116_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	117	0	1	01	01	H5471_117_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	118	0	1	01	01	H5471_118_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	119	0	1	01	01	H5471_119_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	120	0	1	01	01	H5471_120_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	121	0	1	01	01	H5471_121_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	122	0	1	01	01	H5471_122_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	123	0	1	01	01	H5471_123_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	124	0	1	01	01	H5471_124_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	125	0	1	01	01	H5471_125_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	126	0	1	01	01	H5471_126_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	127	0	1	01	01	H5471_127_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	128	0	1	01	01	H5471_128_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	129	0	1	01	01	H5471_129_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	130	0	1	01	01	H5471_130_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	131	0	1	01	01	H5471_131_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1200.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	132	0	1	01	01	H5471_132_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	133	0	1	01	01	H5471_133_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	134	0	1	01	01	H5471_134_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	135	0	1	01	01	H5471_135_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	136	0	1	01	01	H5471_136_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	137	0	1	01	01	H5471_137_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	138	0	1	01	01	H5471_138_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	139	0	1	01	01	H5471_139_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	140	0	1	01	01	H5471_140_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	141	0	1	01	01	H5471_141_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	142	0	1	01	01	H5471_142_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5471	143	0	1	01	01	H5471_143_0	7	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5472	001	0	1	02	01	H5472_001_0	7	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	002	0	1	02	01	H5472_002_0	7	2				2				2				2		1	2	1		2000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	003	0	1	02	01	H5472_003_0	10	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																																																																																																																																																																																		
H5472	004	0	1	02	01	H5472_004_0	6	2				2				2				2		1	2	1		3600.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	007	0	1	02	01	H5472_007_0	7	2				2				2				2		1	2	1		2700.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	009	0	1	02	01	H5472_009_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H5472	010	0	1	02	01	H5472_010_0	7	2				2				2				2		1	2	2					2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																																																																																																																																																																																		
H5472	801	0	1	01	01	H5472_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5472	802	0	1	01	01	H5472_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5472	803	0	1	01	01	H5472_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5472	804	0	1	01	01	H5472_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5475	001	0	1	02	01	H5475_001_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5475	026	0	1	02	01	H5475_026_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5475	031	0	1	02	01	H5475_031_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5475	038	0	1	02	01	H5475_038_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5475	039	0	1	02	01	H5475_039_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5493	001	0	1	20	08	H5493_001_0	2																																																																																																																																																																																																																																																																																																		
H5493	002	0	1	20	08	H5493_002_0	2																																																																																																																																																																																																																																																																																																		
H5496	005	0	1	01	01	H5496_005_0	5	2				2				2				2		2	2	1		500.00	3		2				2					2					2		2	2	1	6	Intraoral Exams – 1 every 12 months	2				2				2	2	2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2					2		2	1				2				2				2	2	2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2				2				2	2	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H5496	012	0	1	01	01	H5496_012_0	5	2				2				2				2		2	2	1		500.00	3		2				2					2					2		2	2	1	6	Intraoral Exams – 1 every 12 months	2				2				2	2	2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				2	2	2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2				2				2	2	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H5496	016	0	1	01	01	H5496_016_0	4	2				2				2				2		2	2	1		500.00	3		2				2					2					2		2	2	1	6	Intraoral Exams – 1 every 12 months	2				2				2	2	2	2	1	6	Bitewings – 1 every six monthsPanoramic radiographic image – 1 every 12 monthsDiagnostic casts – 1 every 12 months	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		1500.00	3		2					2		2	1				2				2				2	2	2	2	1	6	Yearly amounts do not roll overEndodontic covered services – 1 tooth per lifetime	2				2				2	2	2	2	1	6	Yearly amounts do not roll overFull mouth periodontal scaling – 1 every six monthsOther covered periodontal – 1 every 24 months	2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H5521	015	0	1	04	01	H5521_015_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	016	0	1	04	01	H5521_016_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	020	0	1	04	01	H5521_020_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	022	0	1	04	01	H5521_022_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	033	0	1	04	01	H5521_033_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	037	0	1	04	01	H5521_037_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	055	0	1	04	01	H5521_055_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	077	0	1	04	01	H5521_077_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	081	0	1	04	01	H5521_081_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	084	0	1	04	01	H5521_084_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	085	0	1	04	01	H5521_085_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	086	0	1	04	01	H5521_086_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	087	0	1	04	01	H5521_087_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	088	0	1	04	01	H5521_088_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	089	0	1	04	01	H5521_089_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	091	0	1	04	01	H5521_091_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	095	0	1	04	01	H5521_095_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	099	0	1	04	01	H5521_099_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	116	0	1	04	01	H5521_116_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	119	0	1	04	01	H5521_119_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	120	0	1	04	01	H5521_120_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	121	0	1	04	01	H5521_121_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	122	0	1	04	01	H5521_122_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	123	0	1	04	01	H5521_123_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	124	0	1	04	01	H5521_124_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	139	0	1	04	01	H5521_139_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	140	0	1	04	01	H5521_140_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	141	0	1	04	01	H5521_141_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	150	0	1	04	01	H5521_150_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	156	0	1	04	01	H5521_156_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	157	0	1	04	01	H5521_157_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	159	0	1	04	01	H5521_159_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	160	0	1	04	01	H5521_160_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	169	0	1	04	01	H5521_169_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	170	0	1	04	01	H5521_170_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	171	0	1	04	01	H5521_171_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	194	0	1	04	01	H5521_194_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	195	0	1	04	01	H5521_195_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	207	0	1	04	01	H5521_207_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	211	0	1	04	01	H5521_211_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	214	0	1	04	01	H5521_214_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	215	0	1	04	01	H5521_215_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	218	0	1	04	01	H5521_218_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	219	0	1	04	01	H5521_219_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	223	0	1	04	01	H5521_223_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	224	0	1	04	01	H5521_224_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	227	0	1	04	01	H5521_227_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	229	0	1	04	01	H5521_229_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	231	0	1	04	01	H5521_231_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	233	0	1	04	01	H5521_233_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	235	0	1	04	01	H5521_235_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	236	0	1	04	01	H5521_236_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	241	0	1	04	01	H5521_241_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	243	0	1	04	01	H5521_243_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	245	0	1	04	01	H5521_245_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	246	0	1	04	01	H5521_246_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	249	0	1	04	01	H5521_249_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	250	0	1	04	01	H5521_250_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	251	0	1	04	01	H5521_251_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	254	0	1	04	01	H5521_254_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	260	0	1	04	01	H5521_260_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	261	0	1	04	01	H5521_261_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	263	0	1	04	01	H5521_263_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	269	0	1	04	01	H5521_269_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	270	0	1	04	01	H5521_270_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	271	0	1	04	01	H5521_271_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	272	0	1	04	01	H5521_272_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	273	0	1	04	01	H5521_273_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	275	0	1	04	01	H5521_275_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	277	0	1	04	01	H5521_277_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	279	0	1	04	01	H5521_279_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	285	0	1	04	01	H5521_285_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	286	0	1	04	01	H5521_286_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	289	0	1	04	01	H5521_289_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	292	0	1	04	01	H5521_292_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	296	0	1	04	01	H5521_296_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	299	0	1	04	01	H5521_299_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	302	0	1	04	01	H5521_302_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	303	0	1	04	01	H5521_303_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	305	0	1	04	01	H5521_305_0	2	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	306	0	1	04	01	H5521_306_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	314	0	1	04	01	H5521_314_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	319	0	1	04	01	H5521_319_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	320	0	1	04	01	H5521_320_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	322	0	1	04	01	H5521_322_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	323	0	1	04	01	H5521_323_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	324	0	1	04	01	H5521_324_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	326	0	1	04	01	H5521_326_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	329	0	1	04	01	H5521_329_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	330	0	1	04	01	H5521_330_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	340	0	1	04	01	H5521_340_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	348	0	1	04	01	H5521_348_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	351	0	1	04	01	H5521_351_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	352	0	1	04	01	H5521_352_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	353	0	1	04	01	H5521_353_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	363	0	1	04	01	H5521_363_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	364	0	1	04	01	H5521_364_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	365	0	1	04	01	H5521_365_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	369	0	1	04	01	H5521_369_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	375	0	1	04	01	H5521_375_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	378	0	1	04	01	H5521_378_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	381	0	1	04	01	H5521_381_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	388	0	1	04	01	H5521_388_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	392	0	1	04	01	H5521_392_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	395	0	1	04	01	H5521_395_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	398	0	1	04	01	H5521_398_0	2	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	399	0	1	04	01	H5521_399_0	2	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	400	0	1	04	01	H5521_400_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	403	0	1	04	01	H5521_403_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	404	0	1	04	01	H5521_404_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	406	0	1	04	01	H5521_406_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	407	0	1	04	01	H5521_407_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	414	0	1	04	01	H5521_414_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	419	0	1	04	01	H5521_419_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	422	0	1	04	01	H5521_422_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	425	0	1	04	01	H5521_425_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	431	0	1	04	01	H5521_431_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	432	0	1	04	01	H5521_432_0	2	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	433	0	1	04	01	H5521_433_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2250.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	434	0	1	04	01	H5521_434_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	435	0	1	04	01	H5521_435_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	439	0	1	04	01	H5521_439_0	2	2				2				1	75.00	75.00	75.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	443	0	1	04	01	H5521_443_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	446	0	1	04	01	H5521_446_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	449	0	1	04	01	H5521_449_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	450	0	1	04	01	H5521_450_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	451	0	1	04	01	H5521_451_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	457	0	1	04	01	H5521_457_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	461	0	1	04	01	H5521_461_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	464	0	1	04	01	H5521_464_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	465	0	1	04	01	H5521_465_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	467	0	1	04	01	H5521_467_0	3	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	470	0	1	04	01	H5521_470_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	472	0	1	04	01	H5521_472_0	2	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	475	0	1	04	01	H5521_475_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	476	0	1	04	01	H5521_476_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	477	0	1	04	01	H5521_477_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	478	0	1	04	01	H5521_478_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	480	0	1	04	01	H5521_480_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	482	0	1	04	01	H5521_482_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	484	0	1	04	01	H5521_484_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	487	0	1	04	01	H5521_487_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	488	0	1	04	01	H5521_488_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	490	0	1	04	01	H5521_490_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	492	0	1	04	01	H5521_492_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	493	0	1	04	01	H5521_493_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	495	0	1	04	01	H5521_495_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	496	0	1	04	01	H5521_496_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	500	0	1	04	01	H5521_500_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	501	0	1	04	01	H5521_501_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	502	0	1	04	01	H5521_502_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	504	0	1	04	01	H5521_504_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	506	0	1	04	01	H5521_506_0	5	2				1	20	20	20	2				2		1	2	1	2	2250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	510	0	1	04	01	H5521_510_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	512	0	1	04	01	H5521_512_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	513	0	1	04	01	H5521_513_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	520	0	1	04	01	H5521_520_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	521	0	1	04	01	H5521_521_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	522	0	1	04	01	H5521_522_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	536	0	1	04	01	H5521_536_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	537	0	1	04	01	H5521_537_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	553	0	1	04	01	H5521_553_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	554	0	1	04	01	H5521_554_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	558	0	1	04	01	H5521_558_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	569	0	1	04	01	H5521_569_0	2	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	578	0	1	04	01	H5521_578_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	580	0	1	04	01	H5521_580_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	581	0	1	04	01	H5521_581_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	586	0	1	04	01	H5521_586_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	598	0	1	04	01	H5521_598_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	607	0	1	04	01	H5521_607_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	609	0	1	04	01	H5521_609_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	644	0	1	04	01	H5521_644_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	645	0	1	04	01	H5521_645_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	646	0	1	04	01	H5521_646_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	649	0	1	04	01	H5521_649_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	650	0	1	04	01	H5521_650_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	652	0	1	04	01	H5521_652_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	654	0	1	04	01	H5521_654_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	656	0	1	04	01	H5521_656_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	661	0	1	04	01	H5521_661_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	662	0	1	04	01	H5521_662_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	664	0	1	04	01	H5521_664_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	665	0	1	04	01	H5521_665_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	669	0	1	04	01	H5521_669_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	674	0	1	04	01	H5521_674_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	676	0	1	04	01	H5521_676_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	685	0	1	04	01	H5521_685_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	686	0	1	04	01	H5521_686_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	687	0	1	04	01	H5521_687_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5521	688	0	1	04	01	H5521_688_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	698	0	1	04	01	H5521_698_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	699	0	1	04	01	H5521_699_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	702	0	1	04	01	H5521_702_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	704	0	1	04	01	H5521_704_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	705	0	1	04	01	H5521_705_0	2	2				2				1	70.00	70.00	70.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	706	0	1	04	01	H5521_706_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5521	710	0	1	04	01	H5521_710_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5521	801	0	1	04	01	H5521_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5521	805	0	2	04	01	H5521_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	001	0	1	04	01	H5522_001_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	002	0	1	04	01	H5522_002_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	004	0	1	04	01	H5522_004_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	005	0	1	04	01	H5522_005_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	013	0	1	04	01	H5522_013_0	2	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	014	0	1	04	01	H5522_014_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	017	0	1	04	01	H5522_017_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	022	0	1	04	01	H5522_022_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	028	0	1	04	01	H5522_028_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5522	029	0	1	04	01	H5522_029_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	032	0	1	04	01	H5522_032_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H5522	802	0	1	04	01	H5522_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	803	0	1	04	01	H5522_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	808	0	2	04	01	H5522_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	809	0	2	04	01	H5522_809_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	810	0	1	04	01	H5522_810_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	811	0	1	04	01	H5522_811_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	813	0	2	04	01	H5522_813_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	814	0	2	04	01	H5522_814_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	815	0	1	04	01	H5522_815_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	816	0	1	04	01	H5522_816_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	817	0	2	04	01	H5522_817_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	818	0	2	04	01	H5522_818_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	819	0	1	04	01	H5522_819_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	820	0	1	04	01	H5522_820_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	821	0	1	04	01	H5522_821_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	822	0	2	04	01	H5522_822_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	823	0	1	04	01	H5522_823_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	824	0	2	04	01	H5522_824_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	825	0	2	04	01	H5522_825_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	827	0	2	04	01	H5522_827_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	828	0	1	04	01	H5522_828_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	832	0	1	04	01	H5522_832_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	836	0	1	04	01	H5522_836_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	837	0	1	04	01	H5522_837_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5522	838	0	2	04	01	H5522_838_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5525	004	0	1	04	01	H5525_004_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	005	0	1	04	01	H5525_005_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	006	0	1	04	01	H5525_006_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	008	0	1	04	01	H5525_008_0	3	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	030	0	1	04	01	H5525_030_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	031	0	1	04	01	H5525_031_0	1	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5525	034	0	1	04	01	H5525_034_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	035	0	1	04	01	H5525_035_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	036	0	1	04	01	H5525_036_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	041	0	1	04	01	H5525_041_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	042	0	1	04	01	H5525_042_0	3	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	045	0	1	04	01	H5525_045_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	046	0	1	04	01	H5525_046_0	5	2				1	20	20	20	2				2		1	2	1	2	500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, extra-oral x-rays, other diagnostic x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	4	6	3D scans, comp oral exam 1/3 yrs, cone beam CT imaging 1/5 yrs, other diagnostic services 1/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	12	6	caries medicament 3/tooth/yr, counseling services 2/yr, other preventive services 1/tooth/6 mths, perio maint 4/yr, sealant 1/tooth/3 yrs, space maintainer 1 per arch/lifetime	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	5	6	core buildup/prefab post/core 1/tooth/yr, crown recement 1/5 yrs, crown 1/tooth/lifetime, filling unl/yr, other restorative services 2/tooth/yr	2				1	0.00	0.00	0.00	1	2	2	2	4	6	endodontic services, root canal, root canal retreat, therapeutic pulpotomy 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	4	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	maxillofacial prosthetics 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	implant svcs 1/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	alveoloplasty in conjunction with extractions 1 per quadrant/5 yrs, extractions unl, oral surg, removal of impacted tooth 1/tooth/lifetime, oral surg 2/yr, temporomandibular disorder (TMD) 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	8	6	comprehensive orthodontic, harmful habit appliance, other orthodontic 1/lifetime, orthodontic retention 1 per arch/lifetime, periodic orthodontic 4/yr	2				1	0.00	0.00	0.00	1	2	2	2	8	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, non-clinical procedures, sleep apnea, temporomandibular disorder (TMD) 1/lifetime, occlusal adj, occlusal guard 1/3 yrs, parenteral medications 1 per visit	2				1	0.00	0.00	0.00	1	2
H5525	049	0	1	04	01	H5525_049_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	050	0	1	04	01	H5525_050_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5525	051	1	1	04	01	H5525_051_1	3	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	051	2	1	04	01	H5525_051_2	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	054	0	1	04	01	H5525_054_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	056	0	1	04	01	H5525_056_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5525	057	0	1	04	01	H5525_057_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	059	0	1	04	01	H5525_059_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	065	0	1	04	01	H5525_065_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	070	0	1	04	01	H5525_070_0	3	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5525	072	0	1	04	01	H5525_072_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	074	0	1	04	01	H5525_074_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	075	0	1	04	01	H5525_075_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	077	0	1	04	01	H5525_077_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	078	0	1	04	01	H5525_078_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	079	0	1	04	01	H5525_079_0	1	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core 1/tooth/lifetime, crown recement, crown-1/tooth/lifetime, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	080	0	1	04	01	H5525_080_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	083	0	1	04	01	H5525_083_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5525	084	0	1	04	01	H5525_084_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	085	1	1	04	01	H5525_085_1	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	085	2	1	04	01	H5525_085_2	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5525	086	1	1	04	01	H5525_086_1	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	086	2	1	04	01	H5525_086_2	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	087	0	1	04	01	H5525_087_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5525	809	0	1	04	01	H5525_809_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	810	0	1	04	01	H5525_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	812	0	2	04	01	H5525_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	813	0	2	04	01	H5525_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	816	0	1	04	01	H5525_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	817	0	1	04	01	H5525_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	818	0	1	04	01	H5525_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	819	0	1	04	01	H5525_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	826	0	1	04	01	H5525_826_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	827	0	1	04	01	H5525_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	830	0	1	04	01	H5525_830_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5525	831	0	1	04	01	H5525_831_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5526	004	0	1	04	01	H5526_004_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	3		0	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered. Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5526	016	0	1	04	01	H5526_016_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	3		0	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered. Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime.	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5526	018	0	1	04	01	H5526_018_0	5	2				2				1	22.00	22.00	22.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	3		0	50	2				2	2	2	2	1	6	Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, and onlays are not covered. Denture repairs are limited to once per arch per 36 months.	1	50	50	50	2				2	2	2	2	1	6	Coverage for extraction, erupted tooth or exposed root limited to one tooth per lifetime.	1	50	50	50	2				2	2																2	2	2	3		1	50	50	50	2				2	2
H5526	023	0	1	04	01	H5526_023_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	The combination of routine cleaning and periodontal maintenance/cleaning is limited to 2 every year.  Scaling and root planing 1 every 36 months per area of mouth.	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H5526	806	0	1	04	01	H5526_806_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5526	808	0	1	04	01	H5526_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5526	813	0	1	04	01	H5526_813_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5528	807	0	1	04	01	H5528_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5528	815	0	1	04	01	H5528_815_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5533	003	0	1	04	01	H5533_003_0	15	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2	2	350.00	3		2					2		2	1				2				2				2	2																																																																																											2	1				2				2				2	2																														
H5533	005	0	1	04	01	H5533_005_0	15	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	008	0	1	04	01	H5533_008_0	16	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	15.00	15.00	15.00	2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				1	15.00	15.00	15.00	2	2																2	2	2	3		2				2				2	2																															1	2	2	2900.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	011	0	1	04	01	H5533_011_0	17	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	013	0	1	04	01	H5533_013_0	18	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	4700.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	015	1	1	04	01	H5533_015_1	17	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	6000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	015	2	1	04	01	H5533_015_2	17	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	4000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	015	3	1	04	01	H5533_015_3	17	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	4000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	015	4	1	04	01	H5533_015_4	15	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	015	6	1	04	01	H5533_015_6	16	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	016	1	1	04	01	H5533_016_1	14	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	016	2	1	04	01	H5533_016_2	13	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	5000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	017	1	1	04	01	H5533_017_1	15	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2600.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	017	2	1	04	01	H5533_017_2	15	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every 12 months. A panoramic x-ray is offered at a periodicity of 1 every 36 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	2600.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																														
H5533	801	0	1	04	01	H5533_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5533	802	0	1	04	01	H5533_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5533	803	0	1	04	01	H5533_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5538	001	0	1	20	08	H5538_001_0	2																																																																																																																																																																																																																																																																																																		
H5538	002	0	1	20	08	H5538_002_0	2																																																																																																																																																																																																																																																																																																		
H5549	003	0	1	01	01	H5549_003_0	5	2				2				2				2		2	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	2		3500.00	3		2					2		2	2	2	3		2				2				1	2																															2	2	2	3		2				2				1	2																2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																														
H5549	011	0	1	01	01	H5549_011_0	5	2				2				2				2		2	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	2		2750.00	3		2					2		2	2	2	3		2				2				1	2																															2	2	2	3		2				2				1	2																2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																														
H5549	012	0	1	01	01	H5549_012_0	6	2				2				2				2		2	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	2		2500.00	3		2					2		2	2	2	3		2				2				1	2																															2	2	2	3		2				2				1	2																2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																														
H5577	002	0	1	01	01	H5577_002_0	10	2				2				2				2		2	2																																																																																																																1	2		3500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	005	0	1	01	01	H5577_005_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2750.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	008	0	1	02	01	H5577_008_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	016	0	1	01	01	H5577_016_0	7	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	017	0	1	01	01	H5577_017_0	8	2				2				2				2		2	2																																																																																																																1	2		4500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	038	0	1	01	01	H5577_038_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3000.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	042	0	1	01	01	H5577_042_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3000.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	043	0	1	01	01	H5577_043_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3000.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	044	0	1	01	01	H5577_044_0	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		3400.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	046	0	1	01	01	H5577_046_0	9	2				2				2				2		2	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	052	0	1	01	01	H5577_052_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	054	1	1	01	01	H5577_054_1	10	2				2				2				2		2	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	054	2	1	01	01	H5577_054_2	10	2				2				2				2		2	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	054	3	1	01	01	H5577_054_3	9	2				2				2				2		2	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	056	1	1	01	01	H5577_056_1	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		1500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	056	2	1	01	01	H5577_056_2	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		1500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	056	4	1	01	01	H5577_056_4	10	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		1500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	059	0	1	01	01	H5577_059_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	060	0	1	01	01	H5577_060_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				2	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				2	2	1	2		2700.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	061	0	1	01	01	H5577_061_0	9	2				2				2				2		2	2																																																																																																																1	2		4000.00	3		2					2		2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	This service is limited to one (1) per tooth per life. Up to three (3) implants (three (3) teeth) per member per year.	2				2				1	2	2	2	1	6	This service is limited to one (1) per tooth per life.	2				2				1	2	2	2	1	6	Periodicity varies depending on the service.	2				2				1	2																2	2	1	6	Periodicity varies depending on the service and is based on member needs.	2				2				1	2
H5577	062	0	1	01	01	H5577_062_0	10	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	801	0	1	01	01	H5577_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	802	0	1	01	01	H5577_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	809	0	1	01	01	H5577_809_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	818	0	1	01	01	H5577_818_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	820	0	1	01	01	H5577_820_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	821	0	1	01	01	H5577_821_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	822	0	1	01	01	H5577_822_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	824	0	1	01	01	H5577_824_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	827	0	1	01	01	H5577_827_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	829	0	1	01	01	H5577_829_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	830	0	1	01	01	H5577_830_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	831	0	1	01	01	H5577_831_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5577	833	1	1	02	01	H5577_833_1	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	2	1	02	01	H5577_833_2	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	3	1	02	01	H5577_833_3	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	4	1	02	01	H5577_833_4	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	5	1	02	01	H5577_833_5	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	6	1	02	01	H5577_833_6	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	7	1	02	01	H5577_833_7	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	8	1	02	01	H5577_833_8	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	9	1	02	01	H5577_833_9	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	833	10	1	02	01	H5577_833_10	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	1	1	02	01	H5577_834_1	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	2	1	02	01	H5577_834_2	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	3	1	02	01	H5577_834_3	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	4	1	02	01	H5577_834_4	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	5	1	02	01	H5577_834_5	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	6	1	02	01	H5577_834_6	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	7	1	02	01	H5577_834_7	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	8	1	02	01	H5577_834_8	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	9	1	02	01	H5577_834_9	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	834	10	1	02	01	H5577_834_10	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	1	1	02	01	H5577_835_1	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	2	1	02	01	H5577_835_2	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	3	1	02	01	H5577_835_3	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	4	1	02	01	H5577_835_4	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	5	1	02	01	H5577_835_5	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	6	1	02	01	H5577_835_6	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	7	1	02	01	H5577_835_7	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	8	1	02	01	H5577_835_8	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	9	1	02	01	H5577_835_9	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	835	10	1	02	01	H5577_835_10	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	1	1	02	01	H5577_836_1	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	2	1	02	01	H5577_836_2	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	3	1	02	01	H5577_836_3	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	4	1	02	01	H5577_836_4	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	5	1	02	01	H5577_836_5	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	6	1	02	01	H5577_836_6	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	7	1	02	01	H5577_836_7	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	8	1	02	01	H5577_836_8	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	9	1	02	01	H5577_836_9	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	836	10	1	02	01	H5577_836_10	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	1	1	02	01	H5577_837_1	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	2	1	02	01	H5577_837_2	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	3	1	02	01	H5577_837_3	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	4	1	02	01	H5577_837_4	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	5	1	02	01	H5577_837_5	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	6	1	02	01	H5577_837_6	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	7	1	02	01	H5577_837_7	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	8	1	02	01	H5577_837_8	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	9	1	02	01	H5577_837_9	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	837	10	1	02	01	H5577_837_10	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5577	838	0	1	01	01	H5577_838_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5580	001	0	1	01	01	H5580_001_0	2	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H5580	004	0	1	01	01	H5580_004_0	5	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H5580	005	0	1	01	01	H5580_005_0	2	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		5000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H5587	002	0	1	01	01	H5587_002_0	14	2				1	20	20	20	2				2		2	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																													2	1				2				2				2	2																														
H5590	008	0	1	01	01	H5590_008_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5590	010	0	1	01	01	H5590_010_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5591	003	0	1	01	01	H5591_003_0	3	2				2				2				2		1	2	1		2500.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				1	20	20	20	2				2	2	2	2	2	3		2				2				2	2																2	1				1	20	20	20	2				2	2	1	1					2					2		2	1				1	50	50	50	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	50	50	50	2				1	1	2	1				1	50	50	50	2				1	1																2	1				1	50	50	50	2				1	1	2	1				1	50	50	50	2				1	1																														
H5591	006	1	1	02	01	H5591_006_1	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	006	2	1	02	01	H5591_006_2	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	016	0	1	02	01	H5591_016_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		750.00	3		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	017	0	1	02	01	H5591_017_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		750.00	3		2				2					1	110100	50.00	50.00	50.00	2		2	2	2	3		2								2	2	2	2	1	3		2								2	2	2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	2	2	2	3		2								2	2																2	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																2	1				1	50	50	50	1	50.00	50.00	50.00	1	1	2	1				1	50	50	50	1	50.00	50.00	50.00	1	1																														
H5591	018	0	1	02	01	H5591_018_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					1	110100	50.00	50.00	50.00	2		4	2	1	3		2								2	2	2	2	1	3		2								2	2	3													2	2	4	2	1	3		2								2	2																3													2	2																																																																																																																																																																			
H5591	801	0	1	02	01	H5591_801_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5591	802	0	1	02	01	H5591_802_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5593	001	0	1	01	01	H5593_001_0	3	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5593	801	0	1	01	01	H5593_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5594	001	0	1	01	01	H5594_001_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	002	0	1	01	01	H5594_002_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	016	0	1	01	01	H5594_016_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	017	0	1	01	01	H5594_017_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	019	0	1	01	01	H5594_019_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	022	0	1	01	01	H5594_022_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	026	0	1	01	01	H5594_026_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	028	0	1	01	01	H5594_028_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	029	0	1	01	01	H5594_029_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	030	0	1	01	01	H5594_030_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	031	0	1	01	01	H5594_031_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	032	0	1	01	01	H5594_032_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																																													2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	034	0	1	01	01	H5594_034_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	035	0	1	01	01	H5594_035_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2																																																																																																											2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5594	036	0	1	01	01	H5594_036_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	1	2																2	2	7	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2	2	2	2	6	Number of visits is determined by the services listed in the notes section.	2				1	0.00	0.00	0.00	2	2																																														2	2	2	3		2				1	0.00	0.00	0.00	2	2																														
H5599	002	0	1	02	01	H5599_002_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5599	003	0	1	01	01	H5599_003_0	9	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	every 90 days to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 1 plan year	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 3 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	date of sevice to per lifetime	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5599	004	0	1	02	01	H5599_004_0	9	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5599	010	0	1	02	01	H5599_010_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5599	013	1	1	01	01	H5599_013_1	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	every 90 days to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 1 plan year	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 3 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	date of sevice to per lifetime	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5599	013	2	1	01	01	H5599_013_2	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	6	every 90 days to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 1 plan year	2				1	0.00	0.00	0.00	1	2	2	2	1	4		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 3 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	date of sevice to per lifetime	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	every 1 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 1 to 8 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 months to 1 year	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every plan year to per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 2 to 5 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 years	2				1	0.00	0.00	0.00	1	2
H5608	001	0	1	01	01	H5608_001_0	7	2				1	20	20	20	2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Full Mouth XRay: 1/60 monthsIntraoral/Periapical X-Ray: 1/calendar yr, each addl 1/calendar yrBitewing XRay: 1,2,3,4 films 1/calendar yr Vertical bitewing: 7-8 films 1/calendar yr Pano Xray: 1/3 yrs	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Filling (amalgam or resin-based composite indirect) 1 per tooth calendar year	2				2				2	2	2	1				2				2				2	2	2	2	1	6	Periodontal Scaling and Root Planing 1 in 24 monthsPeriodontal Maintenance 1 in 24 monthsFull Mouth Debridement 1 per 3 years	2				2				2	2																																																													2	2	1	6	Gingivectomy or gingivoplasty, Gingival flap, including root planing, Osseous surgery, Bone replacement graft, Free soft tissue graft - 1 in 36 months	2				2				2	2																														
H5608	002	0	1	01	01	H5608_002_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		2000.00	3		2				1	111111	40	40	40	2					1	25.00	2	2	2	3						2				2	2	2	2	1	6	Full mouth radiographic image 1/36 mosIntraoral periapical x-ray 4/yrIntraoral occlusal x-ray 1/60 mosBitewing x-ray 1/yrVertical bitewings - 7-8 films 1/yrPanoramic film 1/3 yrs					2				2	2	2	2	2	3						2				2	2	2	2	2	3						2				2	2	2	2	1	3						2				2	2	2	1								2				2	2	1	1					2					1	25.00	2	2	2	6	Limited to 2 filling services per year.	1	40	40	40	2				2	2																2	2	1	2		1	40	40	40	2				2	2																																																																																																									
H5610	001	0	1	20	08	H5610_001_0	2																																																																																																																																																																																																																																																																																																		
H5610	003	0	1	20	08	H5610_003_0	2																																																																																																																																																																																																																																																																																																		
H5619	001	0	1	01	01	H5619_001_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	003	0	1	01	01	H5619_003_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	012	0	1	01	01	H5619_012_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	015	0	1	01	01	H5619_015_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	016	0	1	01	01	H5619_016_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H5619	021	0	1	01	01	H5619_021_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H5619	026	0	1	01	01	H5619_026_0	3	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H5619	038	0	1	01	01	H5619_038_0	6	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	046	0	1	01	01	H5619_046_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	047	0	1	01	01	H5619_047_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	049	0	1	02	01	H5619_049_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	051	0	1	02	01	H5619_051_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	053	0	1	02	01	H5619_053_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	055	0	1	01	01	H5619_055_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	057	0	1	01	01	H5619_057_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	059	0	1	01	01	H5619_059_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5619	061	0	1	01	01	H5619_061_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5619	066	0	1	01	01	H5619_066_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5619	069	0	1	02	01	H5619_069_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5619	071	0	1	01	01	H5619_071_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	075	0	1	01	01	H5619_075_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	083	0	1	01	01	H5619_083_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	089	0	1	01	01	H5619_089_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5619	090	0	1	01	01	H5619_090_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5619	091	0	1	01	01	H5619_091_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5619	093	0	1	01	01	H5619_093_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5619	095	0	1	01	01	H5619_095_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H5619	111	0	1	02	01	H5619_111_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5619	113	0	1	02	01	H5619_113_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	116	0	1	01	01	H5619_116_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	119	0	1	01	01	H5619_119_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	121	0	1	01	01	H5619_121_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		1500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	1	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H5619	122	0	1	01	01	H5619_122_0	2	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	123	0	1	02	01	H5619_123_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	126	0	1	02	01	H5619_126_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	133	0	1	01	01	H5619_133_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5619	135	0	1	01	01	H5619_135_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	137	0	1	01	01	H5619_137_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	143	0	1	01	01	H5619_143_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	145	0	1	01	01	H5619_145_0	5	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5619	146	0	1	01	01	H5619_146_0	5	2				2				1	25.00	25.00	25.00	2		1	1	1		1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H5619	147	0	1	01	01	H5619_147_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	148	0	1	01	01	H5619_148_0	4	2				2				1	0.00	0.00	0.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	150	0	1	01	01	H5619_150_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	151	0	1	01	01	H5619_151_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	152	0	1	01	01	H5619_152_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	157	0	1	01	01	H5619_157_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	159	0	1	01	01	H5619_159_0	5	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	161	0	1	01	01	H5619_161_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	162	0	1	02	01	H5619_162_0	4	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	163	0	1	01	01	H5619_163_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	165	0	1	01	01	H5619_165_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	166	0	1	01	01	H5619_166_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	167	0	1	01	01	H5619_167_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	169	0	1	01	01	H5619_169_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5619	170	0	1	01	01	H5619_170_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	171	0	1	01	01	H5619_171_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	173	0	1	01	01	H5619_173_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5619	174	0	1	01	01	H5619_174_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	177	0	1	01	01	H5619_177_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	178	0	1	01	01	H5619_178_0	3	2				2				1	0.00	0.00	0.00	2		1	1	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H5619	179	0	1	02	01	H5619_179_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H5619	180	0	1	01	01	H5619_180_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	181	0	1	01	01	H5619_181_0	4	2				2				1	30.00	30.00	30.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	182	0	1	01	01	H5619_182_0	5	2				1	20	20	20	2				2		1	2	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5619	183	0	1	01	01	H5619_183_0	3	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H5619	184	0	1	01	01	H5619_184_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H5619	802	0	1	01	01	H5619_802_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5619	803	0	1	01	01	H5619_803_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5619	805	0	1	01	01	H5619_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5619	806	0	1	01	01	H5619_806_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5622	001	0	1	20	08	H5622_001_0	2																																																																																																																																																																																																																																																																																																		
H5622	002	0	1	20	08	H5622_002_0	2																																																																																																																																																																																																																																																																																																		
H5628	001	0	1	01	01	H5628_001_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H5628	012	0	1	01	01	H5628_012_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1200.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H5628	013	1	1	01	01	H5628_013_1	9	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5628	013	2	1	01	01	H5628_013_2	9	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H5628	014	1	1	01	01	H5628_014_1	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		500.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H5628	014	2	1	01	01	H5628_014_2	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		500.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H5629	001	0	1	20	08	H5629_001_0	2																																																																																																																																																																																																																																																																																																		
H5629	002	0	1	20	08	H5629_002_0	2																																																																																																																																																																																																																																																																																																		
H5644	801	0	1	01	01	H5644_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5644	802	0	1	01	01	H5644_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5644	803	0	1	01	01	H5644_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5649	001	0	1	01	01	H5649_001_0	8	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	1				2				3		0.00	17.00	1	2	2	2	2	3		2				3		0.00	41.00	1	2	2	1				2				3		0.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	13.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2						2					2		2	1				2				3		0.00	424.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	220.00	1	2																2	1				2				3		0.00	2160.00	1	2	2	1				2				3		75.00	295.00	1	2	2	1				2				3		0.00	237.00	1	2																2	1				2				3		0.00	166.00	1	2
H5649	009	0	1	01	01	H5649_009_0	8	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H5649	018	0	1	01	01	H5649_018_0	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	022	0	1	01	01	H5649_022_0	8	2				2				1	0.00	0.00	0.00	2		2	2	2					2				2					2					2		2	1				2				3		0.00	17.00	1	2	2	2	2	3		2				3		0.00	41.00	1	1	2	1				2				3		0.00	15.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	13.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2						2					2		2	1				2				3		0.00	424.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	220.00	1	2																2	1				2				3		0.00	2160.00	1	2	2	1				2				3		75.00	295.00	1	2	2	1				2				3		0.00	237.00	1	2																2	1				2				3		0.00	166.00	1	2
H5649	023	0	1	01	01	H5649_023_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	024	0	1	01	01	H5649_024_0	9	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H5649	025	1	1	01	01	H5649_025_1	8	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	1				2				3		0.00	6.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	1				2				3		0.00	20.00	1	1	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	025	2	1	01	01	H5649_025_2	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	025	3	1	01	01	H5649_025_3	9	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	025	4	1	01	01	H5649_025_4	10	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	026	1	1	01	01	H5649_026_1	9	2				2				1	0.00	0.00	0.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H5649	026	2	1	01	01	H5649_026_2	9	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H5649	026	3	1	01	01	H5649_026_3	9	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H5649	026	4	1	01	01	H5649_026_4	10	2				2				1	0.00	0.00	0.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2
H5649	027	0	1	01	01	H5649_027_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	028	0	1	01	01	H5649_028_0	10	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	1	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	029	0	1	01	01	H5649_029_0	11	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5649	030	0	1	01	01	H5649_030_0	8	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	6.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	1				2				3		0.00	20.00	1	2	2						2					2		2	1				2				3		25.00	400.00	1	2	2	1				2				3		25.00	720.00	1	2	2	1				2				3		0.00	780.00	1	2	2	1				2				3		0.00	600.00	1	2																2	1				2				3		45.00	2160.00	1	2	2	1				2				3		0.00	840.00	1	2	2	1				2				3		0.00	380.00	1	2																2	1				2				3		0.00	300.00	1	2
H5652	001	0	1	02	01	H5652_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5652	002	0	1	02	01	H5652_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5652	003	0	1	02	01	H5652_003_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5652	004	0	1	02	01	H5652_004_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5652	006	0	1	02	01	H5652_006_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5652	008	0	1	02	01	H5652_008_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H5692	001	0	1	01	01	H5692_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5703	001	0	1	01	01	H5703_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																2						2					2		2	2	1	3		2				2				2	2																																																																																																																																							
H5718	001	0	1	04	01	H5718_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5718	002	0	1	04	01	H5718_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5718	003	0	1	04	01	H5718_003_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5718	004	0	1	04	01	H5718_004_0	6	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5718	005	0	1	04	01	H5718_005_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5718	006	0	1	04	01	H5718_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H5734	001	0	1	01	01	H5734_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5774	022	0	1	01	01	H5774_022_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	028	0	1	01	01	H5774_028_0	5	2				2				2				2		2	2																																																																																																																1	2		1500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	031	0	1	02	01	H5774_031_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		2000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	035	0	1	01	01	H5774_035_0	5	2				2				2				2		1	2																																																																																																																1	2		1500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	038	0	1	01	01	H5774_038_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		3000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	1	1	01	01	H5774_041_1	5	2				2				2				2		1	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	2	1	01	01	H5774_041_2	5	2				2				2				2		1	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	3	1	01	01	H5774_041_3	5	2				2				2				2		1	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	4	1	01	01	H5774_041_4	5	2				2				2				2		1	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	041	5	1	01	01	H5774_041_5	5	2				2				2				2		1	2																																																																																																																1	2		1200.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	1	1	01	01	H5774_043_1	6	2				2				2				2		1	2																																																																																																																1	2		3000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	2	1	01	01	H5774_043_2	6	2				2				2				2		1	2																																																																																																																1	2		3000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	3	1	01	01	H5774_043_3	6	2				2				2				2		1	2																																																																																																																1	2		3000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	4	1	01	01	H5774_043_4	7	2				2				2				2		1	2																																																																																																																1	2		3000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	043	5	1	01	01	H5774_043_5	7	2				2				2				2		1	2																																																																																																																1	2		3000.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	046	0	1	01	01	H5774_046_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association(ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures  established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																															2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2
H5774	047	1	1	01	01	H5774_047_1	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	047	2	1	01	01	H5774_047_2	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	047	3	1	01	01	H5774_047_3	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	047	4	1	01	01	H5774_047_4	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	047	5	1	01	01	H5774_047_5	6	2				2				2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Up to one (1) panoramic radiographic image or complete series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both.	2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				2	2	1	2		2500.00	3		2					2		2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2	2	2	1	6	'Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).	2				2				1	2																2	2	1	6	Services are administered with the CDT codes and procedures established by the American Dental Association (ADA)	2				2				1	2
H5774	802	0	1	01	01	H5774_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	808	0	1	01	01	H5774_808_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	809	0	1	01	01	H5774_809_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	810	0	1	01	01	H5774_810_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	811	0	1	01	01	H5774_811_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	812	0	1	02	01	H5774_812_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	814	0	1	02	01	H5774_814_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	816	0	1	02	01	H5774_816_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	818	0	1	02	01	H5774_818_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	820	0	1	02	01	H5774_820_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	821	0	1	02	01	H5774_821_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	822	0	1	02	01	H5774_822_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	823	0	1	02	01	H5774_823_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	824	0	1	02	01	H5774_824_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	825	0	1	02	01	H5774_825_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	826	0	1	01	01	H5774_826_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	827	0	1	01	01	H5774_827_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	828	0	1	01	01	H5774_828_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	829	0	1	01	01	H5774_829_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	830	0	1	01	01	H5774_830_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5774	831	0	1	01	01	H5774_831_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5779	002	0	1	01	01	H5779_002_0	7	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5779	007	0	1	01	01	H5779_007_0	7	2				2				3		10.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5779	009	0	1	01	01	H5779_009_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H5779	010	0	1	01	01	H5779_010_0	7	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2	2	2	1	6	every date of service to 5 years	1	40	40	40	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H5779	011	0	1	01	01	H5779_011_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5793	001	0	1	02	01	H5793_001_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5793	010	0	1	02	01	H5793_010_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	014	0	1	02	01	H5793_014_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	015	0	1	02	01	H5793_015_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H5793	017	0	1	02	01	H5793_017_0	2	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	018	0	1	02	01	H5793_018_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	019	0	1	02	01	H5793_019_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	020	0	1	02	01	H5793_020_0	2	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H5793	801	0	1	01	01	H5793_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5793	802	0	1	01	01	H5793_802_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5810	014	0	1	01	01	H5810_014_0	8	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set full, partial, or immediate every 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H5822	001	0	1	20	08	H5822_001_0	2																																																																																																																																																																																																																																																																																																		
H5822	002	0	1	20	08	H5822_002_0	2																																																																																																																																																																																																																																																																																																		
H5823	010	0	1	01	01	H5823_010_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		500.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H5823	013	1	1	01	01	H5823_013_1	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2500.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H5823	013	2	1	01	01	H5823_013_2	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H5826	014	0	1	01	01	H5826_014_0	5	2				1	20	20	20	2				2		2	2	1		2250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5826	017	0	1	01	01	H5826_017_0	6	2				2				2				2		2	2	1		1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5828	001	0	1	01	01	H5828_001_0	6	2				1	20	20	20	2				2		1	2	1		6000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5828	002	0	1	01	01	H5828_002_0	6	2				1	20	20	20	2				2		1	2	1		5500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5828	008	0	1	02	01	H5828_008_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		3000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	013	0	1	02	01	H5828_013_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	014	0	1	02	01	H5828_014_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	015	0	1	02	01	H5828_015_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	016	0	1	02	01	H5828_016_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	017	0	1	02	01	H5828_017_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5828	018	0	1	01	01	H5828_018_0	6	2				1	20	20	20	2				2		1	2	1		6000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5843	001	0	1	01	01	H5843_001_0	7	2				1	20	20	20	2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	1 bitewing (1-4) images per 12 mos.  1 intraoral-complete series of radiographic images, vertical bitewings, panoramic image every 36 mos.  2 intraoral-occlusal radiographic images per 24 mos.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	See note.	1	50	50	50	2				1	2	2	2	1	6	Pulpotomy or pupal debridement, root canals, apicoectomy, retrograde filling-1 per tooth per lifetime.	1	50	50	50	2				1	2	2	2	1	6	See note.	1	50	50	50	2				1	2	2	2	1	6	See note.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				1	2																2	2	1	6	Fixed dentures (bridges) and retainers-1 per tooth per 60 monthsRe-cement, rebond or repair partial dentures- 1 per 24 months after 6 months of placement	1	50	50	50	2				1	2	2	2	1	6	See note.	1	50	50	50	2				1	2																2	2	1	6	See note.	1	50	50	50	2				1	2
H5852	001	0	1	01	01	H5852_001_0	6	2				2				2				2		1	1	2					2				2					2					2		2	1				2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1550.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5854	012	0	1	02	01	H5854_012_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5854	013	0	1	01	01	H5854_013_0	5	2				1	20	20	20	2				2		1	2	1		1200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5854	018	0	1	02	01	H5854_018_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H5854	019	1	1	01	01	H5854_019_1	4	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H5854	019	2	1	01	01	H5854_019_2	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H5854	020	0	1	01	01	H5854_020_0	5	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H5854	801	0	1	01	01	H5854_801_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5854	803	0	1	01	01	H5854_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5854	806	0	2	01	01	H5854_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5854	807	0	2	01	01	H5854_807_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5854	809	0	1	01	01	H5854_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5854	811	0	2	01	01	H5854_811_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5859	001	0	1	01	01	H5859_001_0	9	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5883	001	1	1	02	01	H5883_001_1	6	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	001	2	1	02	01	H5883_001_2	6	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	001	3	1	02	01	H5883_001_3	6	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	001	4	1	02	01	H5883_001_4	6	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	001	5	1	02	01	H5883_001_5	6	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	002	1	1	02	01	H5883_002_1	7	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	002	2	1	02	01	H5883_002_2	7	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	002	3	1	02	01	H5883_002_3	7	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	002	4	1	02	01	H5883_002_4	7	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	002	7	1	02	01	H5883_002_7	7	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	003	1	1	02	01	H5883_003_1	8	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	003	2	1	02	01	H5883_003_2	7	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	003	3	1	02	01	H5883_003_3	7	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	003	4	1	02	01	H5883_003_4	7	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	003	5	1	02	01	H5883_003_5	7	2				2				3		0.00	200.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical & Full Mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	007	0	1	01	01	H5883_007_0	8	2				2				3		0.00	225.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H5883	014	1	1	02	01	H5883_014_1	7	2				2				3		0.00	375.00	2		2	2	1		950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	2	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2																																																													2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																														
H5883	014	2	1	02	01	H5883_014_2	7	2				2				3		0.00	375.00	2		2	2	1		950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	2	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2																																																													2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																														
H5883	014	4	1	02	01	H5883_014_4	7	2				2				3		0.00	375.00	2		2	2	1		950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	2	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2																																																													2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																														
H5883	014	5	1	02	01	H5883_014_5	7	2				2				3		0.00	375.00	2		2	2	1		950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	2	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2																																																													2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																														
H5883	801	0	1	02	01	H5883_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5883	805	0	1	02	01	H5883_805_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5900	001	0	1	04	01	H5900_001_0	5	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	1	25	25	25	2				2	2	2	2	1	6	Endodontic procedures which include root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	3		0	25	2				2	2	2	2	1	6	Dentures are covered once per 5 year period. Denture relines/repairs are covered two per denture per calendar year after 6 months have elapsed since initial placement.	1	25	25	25	2				2	2																															2	2	1	6	Bridges are covered once per 5 year period. Bridge repairs are covered two per calendar year after 6 months have elapsed since initial placement.	1	25	25	25	2				2	2	2	1				3		0	25	2				2	2																														
H5900	004	0	1	04	01	H5900_004_0	6	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	1200.00	3		2					2		2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	3		25	50	2				2	2	2	2	1	6	Endodontic procedures which include root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	3		0	50	2				2	2	2	2	1	6	Dentures are covered once per 5 year period. Denture relines are covered once per 36 month period; rebase of dentures is covered once per 5 year period; repairs are as needed due to material failure.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per 5 year period.	1	50	50	50	2				2	2	2	2	1	6	Bridges are covered once per 5 year period. Bridge repairs are covered as needed due to material failure.	1	50	50	50	2				2	2	2	1				3		0	50	2				2	2																														
H5900	006	0	1	04	01	H5900_006_0	4	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	1000.00	3		2					2		2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	1	25	25	25	2				2	2	2	2	1	6	Endodontic procedures which include root canals are covered once per tooth per lifetime.	1	25	25	25	2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	3		0	25	2				2	2																																																													2	1				3		0	25	2				2	2																														
H5900	007	0	1	04	01	H5900_007_0	4	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1200.00	3		2					2		2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	1	50	50	50	2				2	2	2	2	1	6	Endodontic procedures which include root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	3		0	50	2				2	2	2	2	1	6	Dentures are covered once per 5 year period. Denture relines are covered once per 36 month period; rebase of dentures is covered once per 5 year period; repairs are as needed due to material failure.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per 5 year period.	1	50	50	50	2				2	2	2	2	1	6	Bridges are covered once per 5 year period. Bridge repairs are covered as needed due to material failure.	1	50	50	50	2				2	2	2	1				3		0	50	2				2	2																														
H5900	008	0	1	04	01	H5900_008_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Various procedures have various benefit frequency limitations. The full list is in the note below.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																		
H5900	801	0	1	04	01	H5900_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5900	802	0	1	04	01	H5900_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5902	001	0	1	20	08	H5902_001_0	2																																																																																																																																																																																																																																																																																																		
H5902	002	0	1	20	08	H5902_002_0	2																																																																																																																																																																																																																																																																																																		
H5926	001	0	1	01	01	H5926_001_0	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year	2				2				1	2
H5926	008	0	1	01	01	H5926_008_0	9	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5926	009	0	1	01	01	H5926_009_0	9	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5928	004	0	1	01	01	H5928_004_0	6	2				2				2				2		2	1	2					2				2					2					2		2	1				2				2				2	2	2	2	1	6	Periodicity range: No frequency limit for panoramic radiographic image, bitewings – 4 radiographic images limited to 1 series every 6 months, intraoral – comprehensive series of radiographic images limited to 1 series every 24 months.	2				3		0.00	5.00	2	2	2	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), assessment of salivary flow by measurement limited to 1 every 12 months.	2				3		0.00	8.00	2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				1	5.00	5.00	5.00	2	2	2	1				2				2				2	2	2						2					2		2	1				2				3		0.00	300.00	1	1	2	1				2				3		15.00	475.00	1	1	2	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	375.00	1	1	2	1				2				3		15.00	500.00	1	1																															2	1				2				3		45.00	570.00	1	1	2	1				2				3		0.00	150.00	1	1	2	1				2				3		0.00	350.00	1	1	2	1				2				3		0.00	105.00	2	2
H5928	010	0	1	01	01	H5928_010_0	6	2				2				3		0.00	30.00	2		2	1	2					2				2					2					2		2	1				2				2				2	2	2	2	1	6	Periodicity range: No frequency limit for panoramic radiographic image, bitewings – 4 radiographic images limited to 1 series every 6 months, intraoral – comprehensive series of radiographic images limited to 1 series every 24 months.	2				3		0.00	5.00	2	2	2	2	1	6	Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), assessment of salivary flow by measurement limited to 1 every 12 months.	2				3		0.00	8.00	2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				1	5.00	5.00	5.00	2	2	2	1				2				2				2	2	2						2					2		2	1				2				3		0.00	300.00	1	1	2	1				2				3		15.00	475.00	1	1	2	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	375.00	1	1	2	1				2				3		15.00	500.00	1	1																															2	1				2				3		45.00	570.00	1	1	2	1				2				3		0.00	150.00	1	1	2	1				2				3		0.00	350.00	1	1	2	1				2				3		0.00	105.00	2	2
H5932	001	0	1	01	01	H5932_001_0	6	2				1	24	24	24	2				2		1	2	1		6500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1					2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H5932	009	0	1	01	01	H5932_009_0	6	2				2				3		30.00	250.00	2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	2				2				2	2																																														2	1				2				2				2	2																														
H5932	012	0	1	01	01	H5932_012_0	6	2				1	24	24	24	2				2		1	2	1		6500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1					2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H5932	013	0	1	01	01	H5932_013_0	6	2				2				3		30.00	250.00	2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	2		2000.00	3		2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	2				2				2	2																																														2	1				2				2				2	2																														
H5934	001	0	1	20	08	H5934_001_0	2																																																																																																																																																																																																																																																																																																		
H5934	002	0	1	20	08	H5934_002_0	2																																																																																																																																																																																																																																																																																																		
H5937	001	0	1	01	01	H5937_001_0	13	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2																																																													2						2					2		2	2	2	6	Restorative service is one crown procedure and one crown repair per year.	2				2				2	2																																																																																																																																							
H5938	001	0	1	01	01	H5938_001_0	8	2				2				1	30.00	30.00	30.00	2		1	1	1		725.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5938	006	0	1	01	01	H5938_006_0	8	2				2				1	20.00	20.00	20.00	2		1	1	1		825.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5938	008	0	1	01	01	H5938_008_0	8	2				2				1	30.00	30.00	30.00	2		1	1	1		625.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H5938	009	0	1	01	01	H5938_009_0	8	2				2				1	30.00	30.00	30.00	2		1	1																																																																																																																																																																																																																																																																																		
H5938	802	0	1	01	01	H5938_802_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5938	803	0	1	01	01	H5938_803_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5938	804	0	1	01	01	H5938_804_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5938	805	0	1	01	01	H5938_805_0	6	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5943	003	0	1	02	01	H5943_003_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5943	004	0	1	02	01	H5943_004_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H5945	001	0	1	01	01	H5945_001_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	002	0	1	01	01	H5945_002_0	7	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	013	0	1	01	01	H5945_013_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	014	0	1	01	01	H5945_014_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	016	0	1	01	01	H5945_016_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	017	0	1	01	01	H5945_017_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5945	018	0	1	01	01	H5945_018_0	7	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H5945	027	0	1	01	01	H5945_027_0	6	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	032	0	1	01	01	H5945_032_0	6	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H5945	801	0	1	01	01	H5945_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5945	802	0	1	01	01	H5945_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5945	804	0	1	01	01	H5945_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5945	805	0	1	01	01	H5945_805_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H5959	009	0	1	04	01	H5959_009_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				3		0	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H5959	010	1	1	04	01	H5959_010_1	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				3		0	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H5959	010	2	1	04	01	H5959_010_2	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	2 routine ORAL EVAL per calendar year 1 COMPREHENSIVE PERIODONTAL EVAL per 3 years 1 DETAILED AND EXTENSIVE ORAL EVAL per 12 months,1 COMBINATION CONSULTATION AND A LIMITED oral eval per 12 months	2				2				1	2	2	2	1	6	4 BITEWING RADIOGRAPH  calendar year, or ONE FULL MOUTH RADIOGRAPH SERIES or INTRAORAL TOMOSYNTHESIS calendar year, or 4 PERIAPICAL IMAGES per 12 months, or one COMPREHENSIVE SERIES per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				3		0	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H5959	011	0	1	04	01	H5959_011_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				3		0	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H5959	012	0	1	04	01	H5959_012_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				1	10.00	10.00	10.00	1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	013	1	1	04	01	H5959_013_1	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				1	10.00	10.00	10.00	1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	013	2	1	04	01	H5959_013_2	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				1	10.00	10.00	10.00	1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2																																2	2	2	3		2				2				1	2																																																																																											2	1				2				2				1	2
H5959	014	1	1	04	01	H5959_014_1	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				3		0	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H5959	014	2	1	04	01	H5959_014_2	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	50	2				1	2	2	1				1	50	50	50	2				1	2	2	1				3		0	50	2				1	2	2	1				1	50	50	50	2				1	2																															2	1				1	50	50	50	2				1	2	2	1				1	50	50	50	2				1	2																2	1				3		0	50	2				1	2
H5959	015	0	1	04	01	H5959_015_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		30	60	2				1	2	2	1				1	60	60	60	2				1	2	2	1				3		0	60	2				1	2	2	1				1	60	60	60	2				1	2																															2	1				1	60	60	60	2				1	2	2	1				1	60	60	60	2				1	2																2	1				3		0	60	2				1	2
H5959	016	0	1	04	01	H5959_016_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				3		50	70	2				1	2	2	1				1	70	70	70	2				1	2	2	1				3		0	70	2				1	2	2	1				1	70	70	70	2				1	2																															2	1				1	70	70	70	2				1	2	2	1				1	70	70	70	2				1	2																2	1				3		0	70	2				1	2
H5959	018	0	1	04	01	H5959_018_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	6	2 routine oral eval per calendar year 1 comprehensive periodontal eval per 3 years 1 detailed and extensive oral eval per 12 months,1 combination consultation and a limited oral eval per 12 months	2				2				1	2	2	2	1	6	4 bitewing radiograph calendar year, or one full mouth radiograph series or intraoral tomosynthesis calendar year, or 4 periapical images per 12 months, or one comprehensive series per 5 years	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2																1	1					2					2		2	1				1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2	2	1				3		0	20	2				1	2	2	1				1	20	20	20	2				1	2																															2	1				1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																2	1				3		0	20	2				1	2
H5959	801	0	1	04	01	H5959_801_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5959	807	0	1	04	01	H5959_807_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5959	808	0	1	04	01	H5959_808_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5959	809	0	1	04	01	H5959_809_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H5965	003	0	1	04	01	H5965_003_0	7	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H5965	004	0	1	04	01	H5965_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5965	006	0	1	04	01	H5965_006_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H5965	008	0	1	04	01	H5965_008_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H5969	002	0	1	01	01	H5969_002_0	5	2				1	20	20	20	2				2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays 2x year.Full Mouth x-rays 1x every 5 years	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																															1	1					2					2		2	2	1	6	Fillings 1x every 24 months. Crowns 1x every 7 Years.	2				2				2	2	2	2	1	6	Root canal: 1x/tooth/lifetimeRetreatment: 1x/tooth/2 years	2				2				2	2	2	2	1	1		2				2				2	2	2	2	1	6	Complete dentures: 1x/ 7 Years.Adjustments: 1x/6 months after insertion	2				2				2	2	2	2	1	6	1x/ 7 Years.	2				2				2	2																2	2	1	6	Full cast noble metal: 1 per tooth per 7 yearsRe-cementing or re-bonding a fixed partial denture: 1x/ year	2				2				2	2	2	2	1	6	1x/tooth/lifetime	2				2				2	2																2	2	1	6	Palliative treatment: 1x/visitFixed partial denture: 1x/fixed partial dentureConsultation: 1x/dentist/yrPost surgical treatment: 1x/dentistInternal bleaching: 1x/tooth/yr	2				2				2	2
H5969	003	0	1	01	01	H5969_003_0	6	2				1	20	20	20	2				2		2	2	1		750.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays 2x year.Full Mouth x-rays 1x every 5 years	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H5970	016	0	1	04	01	H5970_016_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5970	020	0	1	04	01	H5970_020_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2						2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	comp dentures, part dentures 1 every 8 years, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																2	2	1	6	restoration implant 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H5970	028	0	1	04	01	H5970_028_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H5970	029	0	1	04	01	H5970_029_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5970	030	0	1	04	01	H5970_030_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5970	031	0	1	04	01	H5970_031_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5970	032	0	1	04	01	H5970_032_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H5970	801	0	1	04	01	H5970_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	802	0	1	04	01	H5970_802_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	805	0	2	04	01	H5970_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	806	0	2	04	01	H5970_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	816	0	1	04	01	H5970_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	817	0	1	04	01	H5970_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	818	0	1	04	01	H5970_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	819	0	1	04	01	H5970_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	822	0	1	04	01	H5970_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	823	0	1	04	01	H5970_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	828	0	1	04	01	H5970_828_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5970	829	0	1	04	01	H5970_829_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H5978	001	0	1	20	08	H5978_001_0	2																																																																																																																																																																																																																																																																																																		
H5978	002	0	1	20	08	H5978_002_0	2																																																																																																																																																																																																																																																																																																		
H5989	011	0	1	01	01	H5989_011_0	6	2				2				2				2		1	2	1		1000.00	3		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	1				2				2				1	2	1	1					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H5991	010	0	1	01	01	H5991_010_0	5	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				2				1	2	2	2	1	6	Covered for members under age 21; 1 per lifetime	2				2				1	2	2	1				2				2				1	2
H5991	012	1	1	01	01	H5991_012_1	5	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				2				1	2	2	2	1	6	Covered for members under age 21; 1 per lifetime	2				2				1	2	2	1				2				2				1	2
H5991	012	2	1	01	01	H5991_012_2	4	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				2				1	2	2	2	1	6	Covered for members under age 21; 1 per lifetime	2				2				1	2	2	1				2				2				1	2
H5991	013	1	1	01	01	H5991_013_1	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				2				1	2	2	2	1	6	Covered for members under age 21; 1 per lifetime	2				2				1	2	2	1				2				2				1	2
H5991	013	2	1	01	01	H5991_013_2	5	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	2				2				1	2	2	2	1	6	1 per tooth per lifetime	2				2				1	2	2	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery – 1 every 60 month	2				2				1	2	2	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures – 1 per arch per 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	1 every 60 months	2				2				1	2	2	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	2				2				1	2	2	2	1	6	Covered for members under age 21; 1 per lifetime	2				2				1	2	2	1				2				2				1	2
H5992	007	0	1	01	01	H5992_007_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	6	1 periodic oral evaluation per 6 months.1 comprehensive oral evaluation per lifetime per provider/location.1 extensive oral evaluation problem focused per 90 days	2				2				2	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 of screening or assessment of a patient per 10 days1 of diagnostic casts per 12 months by oral surgeon for physically handicapping malocclusion	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	1 of topical application of fluoride varnish per 3 months, 4 per 12 months1 of topical application of fluoride-excluding varnish per 6 months	2				2				2	2	2	2	1	6	2 of application of caries arresting medicament per 12 months, same toothtotal of 4 per lifetime per patient, same tooth	2				2				1	2	2						2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 per lifetime same tooth:pulpotomy, pulpal therapy, root canals, retreatment of root canals, apicoectomy, retrograde filling	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	fixed dentures and associated services-1 per 60 monthsrecement or re-bond fixed dentures-1 per 24 months per quadrantfixed denture repair-1 per 60 months same quadrant	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2																2	2	1	6	Palliative treatment-two per 12 monthsConsultations-1 per 6 monthshospital or ambulatory surgical center-3 per weekoffice visit for observation-4 per 12 monthsocclusal guard-1 per 12 months	2				2				1	2
H5992	010	0	1	01	01	H5992_010_0	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	6	1 periodic oral evaluation per 6 months.1 comprehensive oral evaluation per lifetime per provider/location.1 extensive oral evaluation problem focused per 90 days	2				2				2	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 of screening or assessment of a patient per 10 days1 of diagnostic casts per 12 months by oral surgeon for physically handicapping malocclusion	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	1 of topical application of fluoride varnish per 3 months, 4 per 12 months1 of topical application of fluoride-excluding varnish per 6 months	2				2				2	2	2	2	1	6	2 of application of caries arresting medicament per 12 months, same toothtotal of 4 per lifetime per patient, same tooth	2				2				1	2	2						2					2		2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	1 per lifetime same tooth:pulpotomy, pulpal therapy, root canals, retreatment of root canals, apicoectomy, retrograde filling	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2	2	2	1	6	fixed dentures and associated services-1 per 60 monthsrecement or re-bond fixed dentures-1 per 24 months per quadrantfixed denture repair-1 per 60 months same quadrant	2				2				1	2	2	2	1	6	For periodicity, please see notes.	2				2				1	2																2	2	1	6	Palliative treatment-two per 12 monthsConsultations-1 per 6 monthshospital or ambulatory surgical center-3 per weekoffice visit for observation-4 per 12 monthsocclusal guard-1 per 12 months	2				2				1	2
H5993	001	0	1	20	08	H5993_001_0	2																																																																																																																																																																																																																																																																																																		
H5993	002	0	1	20	08	H5993_002_0	2																																																																																																																																																																																																																																																																																																		
H5995	004	0	1	01	01	H5995_004_0	7	2				2				2				2		2	2	1		200.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6018	002	0	1	04	01	H6018_002_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6018	003	0	1	04	01	H6018_003_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6018	007	0	1	04	01	H6018_007_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6018	008	0	1	04	01	H6018_008_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6018	010	0	1	04	01	H6018_010_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6018	011	0	1	04	01	H6018_011_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6019	001	0	1	01	01	H6019_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6059	001	0	1	20	08	H6059_001_0	2																																																																																																																																																																																																																																																																																																		
H6059	002	0	1	20	08	H6059_002_0	2																																																																																																																																																																																																																																																																																																		
H6078	801	0	1	04	01	H6078_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6078	802	0	1	04	01	H6078_802_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6078	803	0	1	04	01	H6078_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6078	804	0	1	04	01	H6078_804_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6078	805	0	2	04	01	H6078_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6078	806	0	2	04	01	H6078_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6079	001	0	1	20	08	H6079_001_0	2																																																																																																																																																																																																																																																																																																		
H6079	002	0	1	20	08	H6079_002_0	2																																																																																																																																																																																																																																																																																																		
H6081	001	0	1	20	08	H6081_001_0	3																																																																																																																																																																																																																																																																																																		
H6081	002	0	1	20	08	H6081_002_0	3																																																																																																																																																																																																																																																																																																		
H6130	801	0		07	02	H6130_801_0	1																																																																																																																																																																																																																																																																																																		
H6130	802	0		07	02	H6130_802_0	1																																																																																																																																																																																																																																																																																																		
H6130	803	0		07	02	H6130_803_0	1																																																																																																																																																																																																																																																																																																		
H6130	804	0		07	02	H6130_804_0	1																																																																																																																																																																																																																																																																																																		
H6130	805	0		07	02	H6130_805_0	1																																																																																																																																																																																																																																																																																																		
H6130	806	0		07	02	H6130_806_0	1																																																																																																																																																																																																																																																																																																		
H6130	807	0		07	02	H6130_807_0	1																																																																																																																																																																																																																																																																																																		
H6130	808	0		07	02	H6130_808_0	1																																																																																																																																																																																																																																																																																																		
H6130	809	0		07	02	H6130_809_0	1																																																																																																																																																																																																																																																																																																		
H6130	810	0		07	02	H6130_810_0	1																																																																																																																																																																																																																																																																																																		
H6130	811	0		07	02	H6130_811_0	1																																																																																																																																																																																																																																																																																																		
H6130	812	0		07	02	H6130_812_0	1																																																																																																																																																																																																																																																																																																		
H6130	813	0		07	02	H6130_813_0	1																																																																																																																																																																																																																																																																																																		
H6130	814	0		07	02	H6130_814_0	1																																																																																																																																																																																																																																																																																																		
H6130	815	0		07	02	H6130_815_0	1																																																																																																																																																																																																																																																																																																		
H6130	816	0		07	02	H6130_816_0	1																																																																																																																																																																																																																																																																																																		
H6130	817	0		07	02	H6130_817_0	1																																																																																																																																																																																																																																																																																																		
H6130	818	0		07	02	H6130_818_0	1																																																																																																																																																																																																																																																																																																		
H6147	001	0	1	20	08	H6147_001_0	2																																																																																																																																																																																																																																																																																																		
H6147	002	0	1	20	08	H6147_002_0	2																																																																																																																																																																																																																																																																																																		
H6154	001	0	1	02	01	H6154_001_0	4	2				2				3		0.00	65.00	2		2	2	1		300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6158	001	0	1	01	01	H6158_001_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	3		1	20	20	20	2				2	2																2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2				2	2	2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1	20	20	20	2				2	2																																														2	1				1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H6158	003	0	1	01	01	H6158_003_0	5	2				2				1	30.00	30.00	30.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	3		1	20	20	20	2				2	2																2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2				2	2	2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1	20	20	20	2				2	2																																														2	1				1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H6170	001	0	1	02	01	H6170_001_0	9	2				1	0	0	0	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	002	0	1	02	01	H6170_002_0	12	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	003	0	1	02	01	H6170_003_0	10	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	007	0	1	01	01	H6170_007_0	8	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	008	0	1	01	01	H6170_008_0	7	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	009	0	1	01	01	H6170_009_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6170	010	0	1	01	01	H6170_010_0	10	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6188	001	0	1	20	08	H6188_001_0	2																																																																																																																																																																																																																																																																																																		
H6188	002	0	1	20	08	H6188_002_0	2																																																																																																																																																																																																																																																																																																		
H6200	001	0	1	04	01	H6200_001_0	9	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1840.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	004	0	1	04	01	H6200_004_0	8	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	006	0	1	04	01	H6200_006_0	8	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	008	0	1	04	01	H6200_008_0	7	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H6200	009	0	1	04	01	H6200_009_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1	2	850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	010	0	1	04	01	H6200_010_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6200	011	0	1	04	01	H6200_011_0	7	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H6200	801	0	1	04	01	H6200_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6200	802	0	1	04	01	H6200_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6200	803	0	1	04	01	H6200_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6200	804	0	1	04	01	H6200_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6202	003	0	1	04	01	H6202_003_0	5	2				2				1	50.00	50.00	50.00	2		2	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H6202	004	0	1	04	01	H6202_004_0	7	2				2				1	55.00	55.00	55.00	2		2	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H6202	005	0	1	04	01	H6202_005_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H6202	801	0	1	04	01	H6202_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6202	802	0	1	04	01	H6202_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6202	803	0	1	04	01	H6202_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6202	804	0	1	04	01	H6202_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6202	805	0	2	04	01	H6202_805_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6224	001	0	1	01	01	H6224_001_0	5	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1					2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H6231	001	0	1	20	08	H6231_001_0	3																																																																																																																																																																																																																																																																																																		
H6231	002	0	1	20	08	H6231_002_0	3																																																																																																																																																																																																																																																																																																		
H6237	009	0	1	01	01	H6237_009_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	6	Each quadrant every 24 months for root planing/scaling. One every 3 years for full mouth debridement.	1	50	50	50	2				2	2	2	2	1	6	Visit limits vary by service: Complete and partial dentures 1 every 5 years. Complete adjustments, 1 per year. Partial adjustments 2 per year. Repairs 2 per year up to maximum of 5 services in 5 years. Rebase and relines 1 per year	1	50	50	50	2				2	2																																														2	2	1	6	Visit limits vary by service: extractions 2 per year, coronectomy 1 per year	1	50	50	50	2				2	2																														
H6248	001	0	1	01	01	H6248_001_0	4	2				2				2				2		2	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1	2	1				2				2				1	1
H6251	001	0	1	20	08	H6251_001_0	3																																																																																																																																																																																																																																																																																																		
H6251	002	0	1	20	08	H6251_002_0	3																																																																																																																																																																																																																																																																																																		
H6309	001	0	1	04	01	H6309_001_0	8	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1					2					2		2	1				2				2				2	2																2	2	2	3		2				2				2	2																																																																																																									
H6309	002	0	1	04	01	H6309_002_0	6	2				2				1	60.00	60.00	60.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	1	1					2					2		2	1				2				2				2	2																2	2	2	3		2				2				2	2																																																																																																									
H6309	801	0	1	04	01	H6309_801_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6309	802	0	1	04	01	H6309_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6316	002	0	1	01	01	H6316_002_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H6316	005	0	1	01	01	H6316_005_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H6317	001	0	1	20	08	H6317_001_0	2																																																																																																																																																																																																																																																																																																		
H6317	002	0	1	20	08	H6317_002_0	2																																																																																																																																																																																																																																																																																																		
H6322	001	0	1	01	01	H6322_001_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	3													2	2	4	2	2	6	See notes	3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	4	1				3		0	50	2				2	2																4	1				2				2				2	2
H6322	002	0	1	01	01	H6322_002_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	3													2	2	4	2	2	6	See notes	3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	4	1				3		0	50	2				2	2																4	1				2				2				2	2
H6322	008	0	1	01	01	H6322_008_0	8	2				2				1	50.00	50.00	50.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing: once/calendar year; Panoramic or full mouth (which include bitewing x-rays): once per 5 year period.  Bitewing not separately payable in same calendar year as full mouth.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	50	50	50	2				2	2	3													2	2	4	2	2	6	See notes	3		0	50	2				2	2	3													2	2																3													2	2	3													2	2	4	1				3		0	50	2				2	2																4	1				2				2				2	2
H6341	001	0	1	01	01	H6341_001_0	6	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		5000.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H6342	001	0	1	20	08	H6342_001_0	3																																																																																																																																																																																																																																																																																																		
H6342	002	0	1	20	08	H6342_002_0	3																																																																																																																																																																																																																																																																																																		
H6345	001	0	1	01	01	H6345_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6345	002	0	1	01	01	H6345_002_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6348	002	0	1	04	01	H6348_002_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H6348	005	0	1	04	01	H6348_005_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H6348	008	0	1	04	01	H6348_008_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H6348	009	0	1	04	01	H6348_009_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H6351	001	0	1	01	01	H6351_001_0	7	2				1	20	20	20	2				2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H6351	004	0	1	01	01	H6351_004_0	8	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H6351	005	0	1	01	01	H6351_005_0	6	2				1	20	20	20	2				2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	2		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H6368	001	0	1	01	01	H6368_001_0	7	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One (D0210 or D0330) every 2 calendar years. Two periapicals (D0220 or D0230) every calendar year.  One set bitewing x-rays (D0220, D0230, D0270, D0272 D0273, D0274 or D0277) every calendar year.	2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		19.00	44.00	1	1																2	2	1	6	One (D4341 or D4342) per quadrant every 2 calendar years. Two (D1110, D4346 or D4910) every calendar year.	2				3		0.00	30.00	1	1																																																													2	2	3	3		2				3		20.00	98.00	1	1																2	2	1	6	Per visit	2				3		0.00	18.00	1	1
H6368	002	0	1	01	01	H6368_002_0	7	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One (D0210 or D0330) every 2 calendar years. Two periapicals (D0220 or D0230) every calendar year.  One set bitewing x-rays (D0220, D0230, D0270, D0272 D0273, D0274 or D0277) every calendar year.	2				2				2	2	2	2	1	2		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2						2					2		2	2	2	3		2				3		19.00	44.00	1	1																2	2	1	6	One (D4341 or D4342) per quadrant every 2 calendar years. Two (D1110, D4346 or D4910) every calendar year.	2				3		0.00	30.00	1	1																																																													2	2	3	3		2				3		20.00	98.00	1	1																2	2	1	6	Per Visit	2				3		0.00	18.00	1	1
H6371	001	0	1	20	08	H6371_001_0	2																																																																																																																																																																																																																																																																																																		
H6371	002	0	1	20	08	H6371_002_0	2																																																																																																																																																																																																																																																																																																		
H6378	001	0	1	01	01	H6378_001_0	6	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		2500.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H6379	001	0	1	01	01	H6379_001_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H6379	002	0	1	01	01	H6379_002_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H6396	017	0	1	01	01	H6396_017_0	6	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2	2	1				2				2				1	2																2	1				2				2				2	2
H6399	001	0	1	01	01	H6399_001_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6425	001	0	1	20	08	H6425_001_0	2																																																																																																																																																																																																																																																																																																		
H6425	002	0	1	20	08	H6425_002_0	2																																																																																																																																																																																																																																																																																																		
H6453	013	1	1	02	01	H6453_013_1	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	013	2	1	02	01	H6453_013_2	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	013	3	1	02	01	H6453_013_3	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	013	4	1	02	01	H6453_013_4	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	013	5	1	02	01	H6453_013_5	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2200.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	017	1	1	02	01	H6453_017_1	12	2				2				1	0.00	0.00	0.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	017	2	1	02	01	H6453_017_2	12	2				2				1	0.00	0.00	0.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	018	1	1	02	01	H6453_018_1	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2700.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	018	2	1	02	01	H6453_018_2	12	2				2				1	0.00	0.00	0.00	2		2	2	1		2700.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	019	0	1	02	01	H6453_019_0	13	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	020	1	1	02	01	H6453_020_1	12	2				2				1	0.00	0.00	0.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	020	2	1	02	01	H6453_020_2	12	2				2				1	0.00	0.00	0.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	One bitewing x-ray per year or one full mouth x-ray every three years.	2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H6453	801	0	1	01	01	H6453_801_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6453	802	0	1	01	01	H6453_802_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6453	803	0	1	01	01	H6453_803_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6453	804	0	1	02	01	H6453_804_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6474	001	0	1	02	01	H6474_001_0	8	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	002	0	1	02	01	H6474_002_0	9	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	003	0	1	02	01	H6474_003_0	8	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	007	0	1	01	01	H6474_007_0	8	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	008	0	1	01	01	H6474_008_0	7	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	009	0	1	01	01	H6474_009_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6474	010	0	1	01	01	H6474_010_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	6	Comprehensive oral exam and comprehensive periodontal evaluation - one every 3 calendar years per provider or location .All others - 2 per calendar year.	2				2				2	2	2	2	1	6	One set of bitewing x-rays (including vertical bitewings) every calendar yearTwo periapical images every calendar yearOne comprehensive intraoral series or one panoramic image once every two calendar years	2				2				2	2	2	2	1	6	Analysis of saliva sample and pulp vitality tests are covered once every 2 calendar years	2				2				2	2	2	2	2	6	Prophylaxis (routine cleanings), periodontal maintenance cleanings, scaling in the presence of inflammation, or any combination thereof twice in a calendar year	2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	2	3		3		20	40	2				1	1	2	2	2	3		1	20	20	20	2				1	1	2	1				1	20	20	20	2				1	1	2	1				1	40	40	40	2				1	1																															2	1				1	40	40	40	2				2	2	2	2	3	6	Extractions are limited to 3 per calendar year.All other oral and maxillofacial surgeries are unlimited up to benefit cap.	1	20	20	20	2				1	1																														
H6515	001	0	1	01	01	H6515_001_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	002	0	1	01	01	H6515_002_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	003	0	1	01	01	H6515_003_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	004	0	1	01	01	H6515_004_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6515	005	0	1	01	01	H6515_005_0	9	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to one every 5 yrs1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery.Palliative treatment per visit-4 every calendar year.	2				2				1	2
H6517	001	0	1	20	08	H6517_001_0	2																																																																																																																																																																																																																																																																																																		
H6517	002	0	1	20	08	H6517_002_0	2																																																																																																																																																																																																																																																																																																		
H6529	004	0	1	01	01	H6529_004_0	7	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years (Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period.) Posterior composite resin restorations are covered services.	2				2				2	2	2	1				2				2				2	2	2	2	2	6	Every year for perio maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	2				2				2	2	2	2	1	6	Every 5 years	2				2				2	2																2	2	1	6	1 implant per tooth per 5 year period	2				2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period.	2				2				2	2	2	2	1	6	1 extraction per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H6537	001	0	1	20	08	H6537_001_0	2																																																																																																																																																																																																																																																																																																		
H6537	002	0	1	20	08	H6537_002_0	2																																																																																																																																																																																																																																																																																																		
H6541	001	0	1	20	08	H6541_001_0	2																																																																																																																																																																																																																																																																																																		
H6541	002	0	1	20	08	H6541_002_0	2																																																																																																																																																																																																																																																																																																		
H6545	001	0	1	04	01	H6545_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6545	010	0	1	04	01	H6545_010_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6550	003	0	1	02	01	H6550_003_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H6550	004	0	1	02	01	H6550_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H6550	009	0	1	02	01	H6550_009_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H6551	001	0	1	20	08	H6551_001_0	3																																																																																																																																																																																																																																																																																																		
H6551	002	0	1	20	08	H6551_002_0	3																																																																																																																																																																																																																																																																																																		
H6566	001	0	1	04	01	H6566_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H6586	001	0	1	04	01	H6586_001_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6586	002	0	1	04	01	H6586_002_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6586	003	0	1	04	01	H6586_003_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6586	005	0	1	04	01	H6586_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6586	006	0	1	04	01	H6586_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6595	003	0	1	02	01	H6595_003_0	4	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H6595	004	0	1	02	01	H6595_004_0	4	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H6595	005	0	1	02	01	H6595_005_0	4	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H6596	001	0	1	20	08	H6596_001_0	5																																																																																																																																																																																																																																																																																																		
H6596	002	0	1	20	08	H6596_002_0	5																																																																																																																																																																																																																																																																																																		
H6622	001	0	1	01	01	H6622_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	004	0	1	01	01	H6622_004_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	007	0	1	01	01	H6622_007_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	008	0	1	01	01	H6622_008_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	013	0	1	02	01	H6622_013_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	014	0	1	02	01	H6622_014_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	015	0	1	01	01	H6622_015_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, extra-oral x-rays, other diagnostic x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	4	6	3D scans, comp oral exam 1/3 yrs, cone beam CT imaging 1/5 yrs, other diagnostic services 1/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	12	6	caries medicament 3/tooth/yr, counseling services 2/yr, other preventive services 1/tooth/6 mths, perio maint 4/yr, sealant 1/tooth/3 yrs, space maintainer 1 per arch/lifetime	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	5	6	core buildup/prefab post/core 1/tooth/yr, crown recement 1/5 yrs, crown 1/tooth/lifetime, filling unl/yr, other restorative services 2/tooth/yr	2				1	0.00	0.00	0.00	1	2	2	2	4	6	endodontic services, root canal, root canal retreat, therapeutic pulpotomy 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	4	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	maxillofacial prosthetics 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	implant svcs 1/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	alveoloplasty in conjunction with extractions 1 per quadrant/5 yrs, extractions unl, oral surg, removal of impacted tooth 1/tooth/lifetime, oral surg 2/yr, temporomandibular disorder (TMD) 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	8	6	comprehensive orthodontic, harmful habit appliance, other orthodontic 1/lifetime, orthodontic retention 1 per arch/lifetime, periodic orthodontic 4/yr	2				1	0.00	0.00	0.00	1	2	2	2	8	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, non-clinical procedures, sleep apnea, temporomandibular disorder (TMD) 1/lifetime, occlusal adj, occlusal guard 1/3 yrs, parenteral medications 1 per visit	2				1	0.00	0.00	0.00	1	2
H6622	017	0	1	01	01	H6622_017_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H6622	018	0	1	01	01	H6622_018_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	021	1	1	02	01	H6622_021_1	2	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	021	2	1	02	01	H6622_021_2	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	022	0	1	02	01	H6622_022_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	023	0	1	02	01	H6622_023_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1		4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	025	0	1	02	01	H6622_025_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H6622	026	0	1	02	01	H6622_026_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6622	027	0	1	02	01	H6622_027_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6622	028	0	1	01	01	H6622_028_0	3	2				2				1	10.00	10.00	10.00	2		1	1	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	1
H6622	029	0	1	01	01	H6622_029_0	3	2				2				1	0.00	0.00	0.00	2		1	1	1		1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	032	0	1	01	01	H6622_032_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	033	0	1	01	01	H6622_033_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	035	0	1	01	01	H6622_035_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	036	0	1	01	01	H6622_036_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	037	0	1	01	01	H6622_037_0	3	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	047	0	1	01	01	H6622_047_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H6622	048	0	1	01	01	H6622_048_0	5	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6622	054	0	1	01	01	H6622_054_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	055	0	1	01	01	H6622_055_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H6622	056	0	1	01	01	H6622_056_0	3	2				2				1	0.00	0.00	0.00	2		1	1	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	1	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	1	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	1
H6622	057	0	1	02	01	H6622_057_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	060	0	1	02	01	H6622_060_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H6622	061	0	1	02	01	H6622_061_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H6622	071	0	1	01	01	H6622_071_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	075	0	1	01	01	H6622_075_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H6622	078	1	1	01	01	H6622_078_1	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	078	2	1	01	01	H6622_078_2	5	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	079	0	1	01	01	H6622_079_0	5	2				1	20	20	20	2				2		1	1	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	081	0	1	01	01	H6622_081_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	082	0	1	01	01	H6622_082_0	3	2				2				1	25.00	25.00	25.00	2		1	1	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	083	0	1	01	01	H6622_083_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H6622	084	0	1	01	01	H6622_084_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	085	0	1	01	01	H6622_085_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	087	0	1	01	01	H6622_087_0	5	2				1	20	20	20	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	5	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, extra-oral x-rays, other diagnostic x-rays 1/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	4	6	3D scans, comp oral exam 1/3 yrs, cone beam CT imaging 1/5 yrs, other diagnostic services 1/yr	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	12	6	caries medicament 3/tooth/yr, counseling services 2/yr, other preventive services 1/tooth/6 mths, perio maint 4/yr, sealant 1/tooth/3 yrs, space maintainer 1 per arch/lifetime	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	5	6	core buildup/prefab post/core 1/tooth/yr, crown recement 1/5 yrs, crown 1/tooth/lifetime, filling unl/yr, other restorative services 2/tooth/yr	2				1	0.00	0.00	0.00	1	2	2	2	4	6	endodontic services, root canal, root canal retreat, therapeutic pulpotomy 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	4	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2	2	2	1	6	maxillofacial prosthetics 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	implant svcs 1/lifetime	2				1	0.00	0.00	0.00	1	2																2	2	7	6	alveoloplasty in conjunction with extractions 1 per quadrant/5 yrs, extractions unl, oral surg, removal of impacted tooth 1/tooth/lifetime, oral surg 2/yr, temporomandibular disorder (TMD) 1/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	8	6	comprehensive orthodontic, harmful habit appliance, other orthodontic 1/lifetime, orthodontic retention 1 per arch/lifetime, periodic orthodontic 4/yr	2				1	0.00	0.00	0.00	1	2	2	2	8	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, non-clinical procedures, sleep apnea, temporomandibular disorder (TMD) 1/lifetime, occlusal adj, occlusal guard 1/3 yrs, parenteral medications 1 per visit	2				1	0.00	0.00	0.00	1	2
H6622	090	0	1	01	01	H6622_090_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H6622	091	0	1	01	01	H6622_091_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H6622	094	0	1	01	01	H6622_094_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H6622	095	0	1	01	01	H6622_095_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H6622	097	0	1	01	01	H6622_097_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H6622	098	0	1	01	01	H6622_098_0	4	2				2				1	15.00	15.00	15.00	2		1	1	1		2000.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	1																2	2	2	1		2				1	25.00	25.00	25.00	1	1																																																																																											2	1				1	0	0	0	2				1	1
H6622	099	1	1	01	01	H6622_099_1	3	2				2				1	25.00	25.00	25.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	099	2	1	01	01	H6622_099_2	3	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	100	1	1	01	01	H6622_100_1	3	2				2				1	20.00	20.00	20.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	100	2	1	01	01	H6622_100_2	3	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H6622	101	0	1	01	01	H6622_101_0	4	2				1	20	20	20	2				2		1	1	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	1	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	1	2	2	2	1		2				1	0.00	0.00	0.00	1	1	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	1																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	1	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	1																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	1
H6622	801	0	1	01	01	H6622_801_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6622	802	0	1	01	01	H6622_802_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6622	804	0	1	01	01	H6622_804_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6622	805	0	1	01	01	H6622_805_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H6652	001	0	1	01	01	H6652_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6672	003	0	1	01	01	H6672_003_0	8	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		2000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H6672	005	0	1	01	01	H6672_005_0	9	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2		3000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H6706	001	0	1	02	01	H6706_001_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H6723	001	1	1	01	01	H6723_001_1	14	2				2				1	35.00	35.00	35.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	001	3	1	01	01	H6723_001_3	14	2				2				1	35.00	35.00	35.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	002	1	1	01	01	H6723_002_1	14	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H6723	002	3	1	01	01	H6723_002_3	14	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H6723	003	1	1	01	01	H6723_003_1	14	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	003	3	1	01	01	H6723_003_3	16	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				1	30	30	30	2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				1	30	30	30	2				2	2	4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2																																																													4	1				1	30	30	30	2				2	2																4	1				1	30	30	30	2				2	2
H6723	006	6	1	02	01	H6723_006_6	15	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H6723	006	7	1	02	01	H6723_006_7	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	4	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H6723	801	0	1	01	01	H6723_801_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6723	802	0	1	01	01	H6723_802_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6723	803	0	1	01	01	H6723_803_0	9	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6743	001	0	1	04	01	H6743_001_0	7	2				2				1	45.00	45.00	45.00	2		2	2	1	2	200.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	007	0	1	04	01	H6743_007_0	10	2				2				1	45.00	45.00	45.00	2		2	2	1	2	300.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																													
H6743	025	0	1	04	01	H6743_025_0	7	2				1	45	45	45	2				2		2	2	1	2	200.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	026	0	1	04	01	H6743_026_0	9	2				2				1	25.00	25.00	25.00	2		2	2	1	2	200.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	027	0	1	04	01	H6743_027_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	400.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	028	0	1	04	01	H6743_028_0	9	2				2				1	35.00	35.00	35.00	2		2	2	1	2	350.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	029	0	1	04	01	H6743_029_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	400.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	030	0	1	04	01	H6743_030_0	8	2				2				1	15.00	15.00	15.00	2		2	2	1	2	350.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	031	0	1	04	01	H6743_031_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1	2	300.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H6743	801	0	1	04	01	H6743_801_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6743	802	0	1	04	01	H6743_802_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6743	803	0	1	04	01	H6743_803_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6743	804	0	1	04	01	H6743_804_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6759	001	0	1	20	08	H6759_001_0	2																																																																																																																																																																																																																																																																																																		
H6759	002	0	1	20	08	H6759_002_0	2																																																																																																																																																																																																																																																																																																		
H6765	001	0	1	01	01	H6765_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6765	002	0	1	01	01	H6765_002_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6776	001	0	1	01	01	H6776_001_0	5	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H6776	002	0	1	01	01	H6776_002_0	5	2				2				2				2		1	2	2					2				2					2					2		2	2	3	6	Periodic Oral evaluation 2 every 6 monthsLimited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months	2				2				2	2	2	2	1	6	Intraoral, complete series - 1 every 36 months.  Intraoral, periapical (D0220) - 3 every 6 months; Intraoral, periapical (D0230, D0240) 6 times every 12 months.Panoramic Radiographic image- 1 every 3 years.	2				2				2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	6	Covered up to age of 20	2				2				2	2	2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.	2				2				2	2	2						2					2		2	2	1	6	Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.	2				2				1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime.	2				2				1	1	2	2	1	6	Gingivectomy/pIasty - 1 every 12 months, per quad. Crown lengthening 1 per tooth per lifetime. Periodontal scaIIng and root pIaning 1 every 24 months per site. Periodontal maintenance once every 6 mo.	2				2				1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).	2				2				1	2	2	2	1	6	1 every 12 months	2				2				1	1	2	2	1	6	Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.	2				2				1	2	2	2	1	6	1 every 60 months, per tooth	2				2				1	2	2	2	1	6	Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime.   Other Oral and Maxillofacial Surgery by report.	2				2				1	1																2	2	1	6	Palliative emergency treatment 2 every 12 months.  Deep sedation maximum of 60 minutes or 4 units	2				2				1	2
H6787	001	0	1	20	08	H6787_001_0	2																																																																																																																																																																																																																																																																																																		
H6787	002	0	1	20	08	H6787_002_0	2																																																																																																																																																																																																																																																																																																		
H6813	001	0	1	04	01	H6813_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6813	006	0	1	04	01	H6813_006_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6815	038	0	1	02	01	H6815_038_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H6815	039	0	1	02	01	H6815_039_0	9	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H6815	040	0	1	02	01	H6815_040_0	6	2				2				3		10.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H6824	001	0	1	04	01	H6824_001_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H6824	002	0	1	04	01	H6824_002_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
H6832	001	0	1	01	01	H6832_001_0	5	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6832	004	0	1	02	01	H6832_004_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3500.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6846	001	0	1	20	08	H6846_001_0	2																																																																																																																																																																																																																																																																																																		
H6846	002	0	1	20	08	H6846_002_0	2																																																																																																																																																																																																																																																																																																		
H6847	001	0	1	02	01	H6847_001_0	7	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	2	1	6	Amalgam and resin fillings 1 per surface per tooth every calendar year Crowns-1 per tooth per 5 calendar years. Re-cementing inlay/onlay, crown, post and core-1 per tooth per calendar year.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	Every 5 years	2				2				2	2																															2	2	1	3		2				2				2	2	2	1				2				2				1	2																2	2	2	3		2				2				1	2
H6847	801	0	1	02	01	H6847_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6847	802	0	1	02	01	H6847_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6847	803	0	1	02	01	H6847_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6851	001	0	1	01	01	H6851_001_0	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	1 every 3 years per tooth on unrestored perm molars	2				2				2	2	1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6851	002	0	1	01	01	H6851_002_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	1 every 3 years per tooth on unrestored perm molars	2				2				2	2	1	2		2000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H6851	003	0	1	01	01	H6851_003_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	1 every 3 years per tooth on unrestored perm molars	2				2				2	2	1	2		4000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H6852	005	0	1	01	01	H6852_005_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	007	0	1	01	01	H6852_007_0	5	2				1	30	30	30	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	008	0	1	01	01	H6852_008_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	009	0	1	01	01	H6852_009_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	010	0	1	01	01	H6852_010_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	011	0	1	01	01	H6852_011_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	012	0	1	01	01	H6852_012_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	013	0	1	01	01	H6852_013_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	014	0	1	01	01	H6852_014_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	015	0	1	01	01	H6852_015_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	016	0	1	01	01	H6852_016_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	017	0	1	01	01	H6852_017_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	018	0	1	01	01	H6852_018_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	019	0	1	01	01	H6852_019_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	020	0	1	01	01	H6852_020_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	021	0	1	01	01	H6852_021_0	6	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	022	0	1	01	01	H6852_022_0	6	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	023	0	1	01	01	H6852_023_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6852	025	0	1	01	01	H6852_025_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6852	026	0	1	01	01	H6852_026_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6868	001	0	1	20	08	H6868_001_0	2																																																																																																																																																																																																																																																																																																		
H6868	002	0	1	20	08	H6868_002_0	2																																																																																																																																																																																																																																																																																																		
H6874	001	0	1	04	01	H6874_001_0	9	2				2				2				2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2																4	2	1	3		2				2				2	2	2	1				2				2				2	2																2						2					2		3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H6874	003	0	1	04	01	H6874_003_0	8	2				2				2				2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2																4	2	1	3		2				2				2	2	2	1				2				2				2	2																2						2					2		3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																3													2	2	3													2	2	3													2	2																3													2	2
H6876	001	0	1	04	01	H6876_001_0	9	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	003	0	1	04	01	H6876_003_0	9	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	004	0	1	04	01	H6876_004_0	9	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	005	0	1	04	01	H6876_005_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	007	0	1	04	01	H6876_007_0	8	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6876	009	0	1	04	01	H6876_009_0	9	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					1	110110	0.00	0.00	0.00	2		2	2	1	4		2								2	2	2	2	1	3		2								2	2																2	2	1	4		2								2	2	2	2	1	3		2								2	2																1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H6887	001	0	1	20	08	H6887_001_0	3																																																																																																																																																																																																																																																																																																		
H6887	002	0	1	20	08	H6887_002_0	3																																																																																																																																																																																																																																																																																																		
H6891	001	0	1	01	01	H6891_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6898	801	0	1	04	01	H6898_801_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6898	802	0	1	04	01	H6898_802_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6898	803	0	1	04	01	H6898_803_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6898	804	0	1	04	01	H6898_804_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6898	805	0	2	04	01	H6898_805_0	4	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6910	001	0	1	01	01	H6910_001_0	6	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H6910	004	0	1	01	01	H6910_004_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H6910	005	0	1	01	01	H6910_005_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2																																																																																											2	2	1	6	1 tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Frequency is unlimited or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H6910	801	0	1	01	01	H6910_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6910	802	0	1	01	01	H6910_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H6941	001	0	1	20	08	H6941_001_0	2																																																																																																																																																																																																																																																																																																		
H6941	002	0	1	20	08	H6941_002_0	2																																																																																																																																																																																																																																																																																																		
H6959	001	0	1	01	01	H6959_001_0	6	2				1	20	20	20	2				2		1	2	1		2675.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H6959	002	0	1	01	01	H6959_002_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to the Notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																															2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2
H6971	001	0	1	01	01	H6971_001_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per visit	2				1	0.00	0.00	0.00	1	2																2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 24 months	2				1	0.00	0.00	0.00	1	2
H6988	004	0	1	01	01	H6988_004_0	7	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	3	6	For limited, Periodic and ComprehensiveLimited oral evaluation 2 every 12 monthsComprehensive oral evaluation 1 per lifetimeOral evaluation, problem focused 3 every 12 months, by reportPeriodic Oral evaluation 2 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral, complete series - 1 every 36 months.  Intraoral, periapical- 3 every 6 months; Intraoral, periapical 6 times every 12 monthsPanoramic Radiographic image- 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every six months.Unspecified preventive procedure, by report.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Amalgam / Resin based composites - 1 per tooth - every 24 monthsCrown services - 1 per tooth - every 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	details listed below	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch.	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	Implants are covered once per tooth per lifetime.  Implant scaling repair is covered once per 12 months.Implant replacements / rebond/ debridement are covered once per tooth 24 months.Implant abutments are covered once per tooth per 96 months. All implant services require prior authorization.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics -Once every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	1 per tooth per lifetime.  Other Oral and Maxillofacial Surgery by report	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Limited to members who are:Exhibit a sever physically handicapping malocclusion	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Office visit, observation - 4 every 12 monthsocclusal guard - 1 every 12 months	2				1	0.00	0.00	0.00	1	2
H6988	006	0	1	02	01	H6988_006_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H6988	007	0	1	02	01	H6988_007_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H6988	008	0	1	02	01	H6988_008_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H6988	009	0	1	02	01	H6988_009_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																		
H6988	010	0	1	02	01	H6988_010_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	2	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H6994	001	0	1	01	01	H6994_001_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6994	002	0	1	01	01	H6994_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6994	003	0	1	01	01	H6994_003_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	004	0	1	01	01	H6994_004_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	008	0	1	01	01	H6994_008_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6994	009	0	1	01	01	H6994_009_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6994	010	0	1	01	01	H6994_010_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H6994	011	0	1	01	01	H6994_011_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6994	012	0	1	01	01	H6994_012_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H6994	013	0	1	01	01	H6994_013_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7003	001	0	1	20	08	H7003_001_0	2																																																																																																																																																																																																																																																																																																		
H7003	002	0	1	20	08	H7003_002_0	2																																																																																																																																																																																																																																																																																																		
H7006	007	0	1	04	01	H7006_007_0	7	2				2				2				2		2	2	1	2	300.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7006	018	0	1	04	01	H7006_018_0	10	2				2				2				2		2	2	1	2	300.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7006	021	0	1	04	01	H7006_021_0	5	2				2				2				2		2	2	1	2	400.00	5		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7006	022	0	1	04	01	H7006_022_0	10	2				2				2				2		2	2	1	2	300.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	005	0	1	01	01	H7020_005_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	010	1	1	01	01	H7020_010_1	5	2				2				1	35.00	35.00	35.00	2		1	2	1		600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	010	2	1	01	01	H7020_010_2	5	2				2				1	45.00	45.00	45.00	2		1	2	1		650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	010	3	1	01	01	H7020_010_3	5	2				2				1	40.00	40.00	40.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	011	1	1	01	01	H7020_011_1	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	011	2	1	01	01	H7020_011_2	5	2				2				1	10.00	10.00	10.00	2		1	2	1		1750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	011	3	1	01	01	H7020_011_3	5	2				2				1	25.00	25.00	25.00	2		1	2	1		1300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7020	801	0	1	01	01	H7020_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7027	001	0	1	20	08	H7027_001_0	3																																																																																																																																																																																																																																																																																																		
H7027	002	0	1	20	08	H7027_002_0	3																																																																																																																																																																																																																																																																																																		
H7028	001	0	1	04	01	H7028_001_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7028	002	0	1	04	01	H7028_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7028	003	0	1	04	01	H7028_003_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7028	004	0	1	04	01	H7028_004_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7028	005	0	1	04	01	H7028_005_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7028	006	0	1	04	01	H7028_006_0	6	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7059	001	0	1	20	08	H7059_001_0	2																																																																																																																																																																																																																																																																																																		
H7059	002	0	1	20	08	H7059_002_0	2																																																																																																																																																																																																																																																																																																		
H7063	001	0	1	04	01	H7063_001_0	3	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2																															4	2	1	3		1	50	50	50	2				2	2	4	2	1	3		1	50	50	50	2				2	2																4	2	1	3		1	50	50	50	2				2	2
H7063	006	0	1	04	01	H7063_006_0	5	2				2				1	40.00	40.00	40.00	2		2	2	1	2	2500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																															2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H7063	007	0	1	04	01	H7063_007_0	3	2				2				1	35.00	35.00	35.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2																															4	2	1	3		2				2				2	2	4	2	1	3		2				2				2	2																4	2	1	3		2				2				2	2
H7063	012	0	1	04	01	H7063_012_0	3	2				2				1	30.00	30.00	30.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																															2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2
H7063	013	0	1	04	01	H7063_013_0	2	2				2				1	45.00	45.00	45.00	2		2	2	1	2	2000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																															2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H7063	801	0	1	04	01	H7063_801_0	1	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7063	802	0	1	04	01	H7063_802_0	1	2				1	30	30	30	2				2		2	2																																																																																																																																																																																																																																																																																		
H7074	001	0	1	04	01	H7074_001_0	8	2				2				2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H7074	801	0	1	04	01	H7074_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H7074	802	0	1	04	01	H7074_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H7074	803	0	1	04	01	H7074_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H7074	804	0	1	04	01	H7074_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H7093	001	0	1	04	01	H7093_001_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7093	002	0	1	04	01	H7093_002_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1	2	2750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7114	001	0	1	20	08	H7114_001_0	2																																																																																																																																																																																																																																																																																																		
H7114	002	0	1	20	08	H7114_002_0	2																																																																																																																																																																																																																																																																																																		
H7115	001	0	1	01	01	H7115_001_0	8	2				2				1	20.00	20.00	20.00	2		2	2	1		2500.00	3		2				2					2					2		2	2	2	3		3		0	20	2				2	2	2	2	2	3		3		0	20	2				2	2	2	2	1	3		3		0	20	2				2	2	2	2	2	3		3		0	20	2				2	2	2	2	2	3		3		0	20	2				2	2	2	2	1	3		1	50	50	50	3		8.80	52.80	2	2	1	1					2					2		2	2	1	6	See notes	1	50	50	50	3		15.40	220.00	2	2	2	2	1	6	See notes	1	50	50	50	3		9.90	364.10	2	2	2	2	1	6	See notes	1	50	50	50	3		5.50	201.30	2	2	2	2	1	6	See notes	1	50	50	50	3		25.30	559.90	2	2																															2	2	1	6	See notes	1	50	50	50	3		137.50	416.90	2	2	2	2	1	6	See notes	1	50	50	50	3		24.20	1129.70	2	2																2	2	1	6	See notes	3		0	50	3		4.40	118.80	2	2
H7115	005	0	1	01	01	H7115_005_0	10	2				1	20	20	20	2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	See notes	2				2				2	2	2	2	1	6	See notes	2				2				2	2	2	2	1	6	See notes	2				2				2	2	2	2	1	6	See notes	2				2				2	2																															2	2	1	6	See notes	2				2				2	2	2	2	1	6	See notes	2				2				2	2																2	2	1	6	See notes	2				2				2	2
H7115	006	0	1	01	01	H7115_006_0	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		3		0	20	2				2	2	2	2	2	3		3		0	20	2				2	2	2	2	1	3		3		0	20	2				2	2	2	2	2	3		3		0	20	2				2	2	2	2	2	3		3		0	20	2				2	2	2	2	1	3		1	50	50	50	3		8.80	52.80	2	2	1	1					2					2		2	2	1	6	See notes	1	50	50	50	3		15.40	220.00	2	2	2	2	1	6	See notes	1	50	50	50	3		9.90	364.10	2	2	2	2	1	6	See notes	1	50	50	50	3		5.50	201.30	2	2	2	2	1	6	See notes	1	50	50	50	3		25.30	559.90	2	2																															2	2	1	6	See notes	1	50	50	50	3		137.50	416.90	2	2	2	2	1	6	See notes	1	50	50	50	3		24.20	1129.70	2	2																2	2	1	6	See notes	3		0	50	3		4.40	118.80	2	2
H7115	805	0	1	01	01	H7115_805_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7115	806	0	1	01	01	H7115_806_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7115	807	0	1	01	01	H7115_807_0	5	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7123	001	0	1	01	01	H7123_001_0	17	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	There are also two types of dental x-rays offered under preventive dental. Bitewing x-ray(s) are offered at a periodicity of 1 every six months. A panoramic x-ray is offered at a periodicity of 1 every 60 months.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		3995.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																														
H7147	001	0	1	01	01	H7147_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7147	003	0	1	01	01	H7147_003_0	6	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	004	0	1	01	01	H7147_004_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7147	007	0	1	01	01	H7147_007_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	009	0	1	01	01	H7147_009_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	010	0	1	01	01	H7147_010_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	011	0	1	01	01	H7147_011_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	012	0	1	01	01	H7147_012_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7147	013	0	1	01	01	H7147_013_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7149	001	0	1	02	01	H7149_001_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7149	006	0	1	01	01	H7149_006_0	2	2				1	20	20	20	2				2		1	2	1		2550.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H7149	007	0	1	02	01	H7149_007_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H7149	801	0	1	01	01	H7149_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7151	001	0	1	01	01	H7151_001_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7151	003	0	1	01	01	H7151_003_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7151	005	0	1	01	01	H7151_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7151	006	0	1	01	01	H7151_006_0	6	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7195	001	0	1	20	08	H7195_001_0	2																																																																																																																																																																																																																																																																																																		
H7195	002	0	1	20	08	H7195_002_0	2																																																																																																																																																																																																																																																																																																		
H7199	002	0	1	04	01	H7199_002_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7220	004	0	1	02	01	H7220_004_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7220	009	1	1	01	01	H7220_009_1	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7220	009	2	1	01	01	H7220_009_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7220	010	0	1	01	01	H7220_010_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H7233	001	0	1	20	08	H7233_001_0	2																																																																																																																																																																																																																																																																																																		
H7233	002	0	1	20	08	H7233_002_0	2																																																																																																																																																																																																																																																																																																		
H7239	001	0	1	01	01	H7239_001_0	7	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		0	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7239	002	0	1	01	01	H7239_002_0	7	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7239	003	0	1	01	01	H7239_003_0	6	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7239	004	0	1	01	01	H7239_004_0	5	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7239	005	0	1	01	01	H7239_005_0	6	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		0	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		0	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		0	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		0	50	2				2	2	2	1				3		0	50	2				2	2																2	1				3		0	50	2				2	2
H7262	001	0	1	20	08	H7262_001_0	2																																																																																																																																																																																																																																																																																																		
H7262	002	0	1	20	08	H7262_002_0	2																																																																																																																																																																																																																																																																																																		
H7275	001	0	1	01	01	H7275_001_0	6	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H7284	001	0	1	04	01	H7284_001_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		1	0	0	0	2				2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	2	2	1	1		1	0	0	0	2				2	2	2	2	2	3		1	0	0	0	2				2	2																2	2	4	3		1	0	0	0	2				2	2	1	1					2					2		2	1				2				1	25.00	25.00	25.00	1	2																2	2	2	1		2				1	25.00	25.00	25.00	1	2																																																																																											2	1				1	0	0	0	2				1	2
H7284	008	0	1	04	01	H7284_008_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2																																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H7284	009	0	1	04	01	H7284_009_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H7284	010	0	1	04	01	H7284_010_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7296	001	0	1	20	08	H7296_001_0	2																																																																																																																																																																																																																																																																																																		
H7296	002	0	1	20	08	H7296_002_0	2																																																																																																																																																																																																																																																																																																		
H7301	002	0	1	04	01	H7301_002_0	2	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	006	0	1	04	01	H7301_006_0	2	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1750.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	007	0	1	04	01	H7301_007_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H7301	009	0	1	04	01	H7301_009_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	013	0	1	04	01	H7301_013_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2250.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	021	0	1	04	01	H7301_021_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	2000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	023	0	1	04	01	H7301_023_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	027	0	1	04	01	H7301_027_0	2	2				2				1	55.00	55.00	55.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H7301	032	0	1	04	01	H7301_032_0	2	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	033	0	1	04	01	H7301_033_0	2	2				2				1	60.00	60.00	60.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H7301	034	0	1	04	01	H7301_034_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H7301	803	0	1	04	01	H7301_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7323	007	0	1	04	01	H7323_007_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H7323	012	0	1	04	01	H7323_012_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H7326	001	0	1	04	01	H7326_001_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H7326	007	0	1	04	01	H7326_007_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H7355	001	0	1	04	01	H7355_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7355	002	0	1	04	01	H7355_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7355	003	0	1	04	01	H7355_003_0	6	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	004	0	1	04	01	H7355_004_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	006	0	1	04	01	H7355_006_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7355	007	0	1	04	01	H7355_007_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	009	0	1	04	01	H7355_009_0	6	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7355	010	0	1	04	01	H7355_010_0	6	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7366	001	0	1	20	08	H7366_001_0	2																																																																																																																																																																																																																																																																																																		
H7366	002	0	1	20	08	H7366_002_0	2																																																																																																																																																																																																																																																																																																		
H7379	001	0	1	04	01	H7379_001_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1000.00	3		2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequencies vary by service	2				3		15.00	30.00	1	2
H7379	002	0	1	04	01	H7379_002_0	7	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1500.00	3		2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequencies vary by service	2				3		15.00	30.00	1	2
H7379	003	0	1	04	01	H7379_003_0	5	2				2				1	40.00	40.00	40.00	2		2	2	2					2				2					2					2		2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Frequencies vary based on type of services.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	2	2	1000.00	3		2					2		2	2	1	6	Frequencies vary based on type of services.	2				3		15.00	400.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		100.00	200.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		50.00	300.00	1	2	2	2	1	6	Frequencies vary based on type of services.	2				3		30.00	700.00	1	2																2	2	1	6	Frequencies vary based on service.	2				3		70.00	500.00	1	2	2	2	1	6	Frequency varies by service.	2				3		40.00	400.00	1	2	2	2	1	6	one tooth per lifetime	2				3		40.00	100.00	1	2																2	2	1	6	Frequency varies by service	2				3		15.00	30.00	1	2
H7379	801	0	1	04	01	H7379_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7379	802	0	1	04	01	H7379_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7379	803	0	1	04	01	H7379_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7379	804	0	1	04	01	H7379_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7389	801	0	1	01	01	H7389_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7397	001	0	1	04	01	H7397_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7397	002	0	1	04	01	H7397_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7397	003	0	1	04	01	H7397_003_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	004	0	1	04	01	H7397_004_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	006	0	1	04	01	H7397_006_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7397	007	0	1	04	01	H7397_007_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	009	0	1	04	01	H7397_009_0	5	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7397	010	0	1	04	01	H7397_010_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7435	001	0	1	01	01	H7435_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per visit	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	per tooth per 6 months	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 24 months	2				1	0.00	0.00	0.00	1	2
H7464	008	1	1	01	01	H7464_008_1	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7464	008	2	1	01	01	H7464_008_2	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7464	010	0	1	01	01	H7464_010_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7464	012	0	1	02	01	H7464_012_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H7469	001	0	1	20	08	H7469_001_0	2																																																																																																																																																																																																																																																																																																		
H7469	002	0	1	20	08	H7469_002_0	2																																																																																																																																																																																																																																																																																																		
H7471	001	0	1	04	01	H7471_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	002	0	1	04	01	H7471_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	004	0	1	04	01	H7471_004_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	005	0	1	04	01	H7471_005_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	006	0	1	04	01	H7471_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	007	0	1	04	01	H7471_007_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	008	0	1	04	01	H7471_008_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	009	0	1	04	01	H7471_009_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	011	0	1	04	01	H7471_011_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	012	0	1	04	01	H7471_012_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7471	013	0	1	04	01	H7471_013_0	6	2				1	30	30	30	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	014	0	1	04	01	H7471_014_0	7	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	015	0	1	04	01	H7471_015_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	016	0	1	04	01	H7471_016_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7471	017	0	1	04	01	H7471_017_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7501	001	0	1	20	08	H7501_001_0	2																																																																																																																																																																																																																																																																																																		
H7501	002	0	1	20	08	H7501_002_0	2																																																																																																																																																																																																																																																																																																		
H7511	001	0	1	01	01	H7511_001_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Limit once every 5 years. Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex is covered once in a five year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	2				2				2	2																2	2	1	3		2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every 2 years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2
H7511	002	0	1	01	01	H7511_002_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Limit once every 5 years. Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex is covered once in a five year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	2				2				2	2																2	2	1	6	Implants are covered once per tooth per five year period	2				2				2	2	2	2	1	2		2				2				2	2	2	2	1	6	Once every five years	2				2				2	2																2	2	1	6	Once every five years	2				2				2	2
H7512	801	0	1	04	01	H7512_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7518	001	0	1	04	01	H7518_001_0	8	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H7518	002	0	1	04	01	H7518_002_0	7	2				2				1	10.00	10.00	10.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H7518	003	0	1	04	01	H7518_003_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H7522	801	0	1	04	01	H7522_801_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	802	0	1	04	01	H7522_802_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	804	0	1	04	01	H7522_804_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	805	0	1	04	01	H7522_805_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	806	0	1	04	01	H7522_806_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	807	0	1	04	01	H7522_807_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	808	0	1	04	01	H7522_808_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	809	0	1	04	01	H7522_809_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	810	0	1	04	01	H7522_810_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	811	0	1	04	01	H7522_811_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	812	0	1	04	01	H7522_812_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	813	0	1	04	01	H7522_813_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	814	0	1	04	01	H7522_814_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7522	815	0	1	04	01	H7522_815_0	2	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H7524	001	0	1	01	01	H7524_001_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7524	002	0	1	01	01	H7524_002_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7524	003	0	1	01	01	H7524_003_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7524	004	0	1	01	01	H7524_004_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	1				2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	1				2				2				1	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H7557	001	0	1	01	01	H7557_001_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7598	003	0	1	01	01	H7598_003_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7598	004	0	1	01	01	H7598_004_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	001	0	1	01	01	H7605_001_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	002	0	1	01	01	H7605_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	004	0	1	01	01	H7605_004_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	005	0	1	01	01	H7605_005_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	007	0	1	01	01	H7605_007_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	008	0	1	01	01	H7605_008_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	009	0	1	01	01	H7605_009_0	7	2				2				1	30.00	30.00	30.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	010	0	1	01	01	H7605_010_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7605	016	0	1	01	01	H7605_016_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7607	014	0	1	01	01	H7607_014_0	12	2				2				2				2		1	2	1		1100.00	4		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	2		2				2				1	2	2	2	1	6	per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No Limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	Every 5 calendar years	2				2				1	2	2	1				2				2				1	1																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	015	0	1	01	01	H7607_015_0	12	2				2				2				2		1	2	1		400.00	4		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	2		2				2				1	2	2	2	1	6	Per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No Limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	Every 5 calendar years	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	016	0	1	01	01	H7607_016_0	11	2				2				2				2		1	2	1		1200.00	4		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	2		2				2				1	2	2	2	1	6	per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	Every 5 calendar years	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7607	017	0	1	01	01	H7607_017_0	11	2				2				2				2		1	2	1		1200.00	4		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	2	1	2		2				2				1	2	2	2	1	6	per lifetime	2				2				1	2	2	2	1	2		2				2				1	2	2	2	1	6	No limit	2				2				1	2																2	2	1	6	Abutment support crown - 1 per tooth every 5 calendar years	2				2				1	2	2	2	1	6	Every 5 calendar years	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Occlusal guard - 1 every 3 calendar years	2				2				2	2
H7617	003	0	1	04	01	H7617_003_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	004	0	1	04	01	H7617_004_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	005	0	1	04	01	H7617_005_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	006	0	1	04	01	H7617_006_0	4	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	007	0	1	04	01	H7617_007_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	008	0	1	04	01	H7617_008_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	009	0	1	04	01	H7617_009_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	010	0	1	04	01	H7617_010_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	011	0	1	04	01	H7617_011_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	012	0	1	04	01	H7617_012_0	2	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	013	0	1	04	01	H7617_013_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	014	0	1	04	01	H7617_014_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	015	0	1	04	01	H7617_015_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	5000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	016	0	1	04	01	H7617_016_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	017	0	1	04	01	H7617_017_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	018	0	1	04	01	H7617_018_0	2	2				2				1	25.00	25.00	25.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	019	0	1	04	01	H7617_019_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	020	0	1	04	01	H7617_020_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	021	0	1	04	01	H7617_021_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	022	0	1	04	01	H7617_022_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	023	0	1	04	01	H7617_023_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	024	0	1	04	01	H7617_024_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	25.00	25.00	25.00	1	2	3													2	2	4	2	2	1		2				1	25.00	25.00	25.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	025	0	1	04	01	H7617_025_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	026	0	1	04	01	H7617_026_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	027	0	1	04	01	H7617_027_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	028	0	1	04	01	H7617_028_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	029	0	1	04	01	H7617_029_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	030	0	1	04	01	H7617_030_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	031	0	1	04	01	H7617_031_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	032	0	1	04	01	H7617_032_0	3	2				2				1	10.00	10.00	10.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	033	0	1	04	01	H7617_033_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H7617	034	0	1	04	01	H7617_034_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	035	0	1	04	01	H7617_035_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	036	0	1	04	01	H7617_036_0	4	2				1	20	20	20	2				2		1	2	1	2	4000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	037	0	1	04	01	H7617_037_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	038	0	1	04	01	H7617_038_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	039	0	1	04	01	H7617_039_0	4	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	040	0	1	04	01	H7617_040_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	041	0	1	04	01	H7617_041_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	042	0	1	04	01	H7617_042_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	043	0	1	04	01	H7617_043_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	044	0	1	04	01	H7617_044_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	045	0	1	04	01	H7617_045_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	046	0	1	04	01	H7617_046_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	048	0	1	04	01	H7617_048_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H7617	049	0	1	04	01	H7617_049_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	050	0	1	04	01	H7617_050_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	051	0	1	04	01	H7617_051_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	052	0	1	04	01	H7617_052_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	053	0	1	04	01	H7617_053_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	054	0	1	04	01	H7617_054_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	055	0	1	04	01	H7617_055_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	056	0	1	04	01	H7617_056_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	057	0	1	04	01	H7617_057_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	058	0	1	04	01	H7617_058_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H7617	059	0	1	04	01	H7617_059_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	060	0	1	04	01	H7617_060_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	061	0	1	04	01	H7617_061_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	062	0	1	04	01	H7617_062_0	1	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	063	0	1	04	01	H7617_063_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	064	0	1	04	01	H7617_064_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	065	0	1	04	01	H7617_065_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	066	0	1	04	01	H7617_066_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	067	0	1	04	01	H7617_067_0	4	2				1	20	20	20	2				2		1	2	1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	068	0	1	04	01	H7617_068_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	069	0	1	04	01	H7617_069_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	070	0	1	04	01	H7617_070_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	071	0	1	04	01	H7617_071_0	2	2				2				1	50.00	50.00	50.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	072	0	1	04	01	H7617_072_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	073	0	1	04	01	H7617_073_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	074	0	1	04	01	H7617_074_0	4	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	075	0	1	04	01	H7617_075_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	076	0	1	04	01	H7617_076_0	4	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	077	0	1	04	01	H7617_077_0	4	2				2				1	15.00	15.00	15.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	078	0	1	04	01	H7617_078_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	079	0	1	04	01	H7617_079_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	080	0	1	04	01	H7617_080_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	081	0	1	04	01	H7617_081_0	4	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	082	0	1	04	01	H7617_082_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H7617	083	0	1	04	01	H7617_083_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	084	0	1	04	01	H7617_084_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	085	0	1	04	01	H7617_085_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	086	0	1	04	01	H7617_086_0	1	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	087	0	1	04	01	H7617_087_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	088	0	1	04	01	H7617_088_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	089	0	1	04	01	H7617_089_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	090	0	1	04	01	H7617_090_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	091	0	1	04	01	H7617_091_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	092	0	1	04	01	H7617_092_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	093	0	1	04	01	H7617_093_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	094	0	1	04	01	H7617_094_0	3	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	095	0	1	04	01	H7617_095_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	096	0	1	04	01	H7617_096_0	1	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	098	0	1	04	01	H7617_098_0	3	2				2				1	15.00	15.00	15.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H7617	100	0	1	04	01	H7617_100_0	3	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	101	0	1	04	01	H7617_101_0	1	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
H7617	107	0	1	04	01	H7617_107_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	108	0	1	04	01	H7617_108_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H7617	109	0	1	04	01	H7617_109_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	110	0	1	04	01	H7617_110_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H7617	111	0	1	04	01	H7617_111_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
H7617	112	0	1	04	01	H7617_112_0	3	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	113	0	1	04	01	H7617_113_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H7617	801	0	1	04	01	H7617_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	802	0	1	04	01	H7617_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	803	0	2	04	01	H7617_803_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	804	0	2	04	01	H7617_804_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	805	0	1	04	01	H7617_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	806	0	1	04	01	H7617_806_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	807	0	1	04	01	H7617_807_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	808	0	1	04	01	H7617_808_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	811	0	1	04	01	H7617_811_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	812	0	1	04	01	H7617_812_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	817	0	1	04	01	H7617_817_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7617	818	0	1	04	01	H7617_818_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7619	001	0	1	20	08	H7619_001_0	2																																																																																																																																																																																																																																																																																																		
H7619	002	0	1	20	08	H7619_002_0	2																																																																																																																																																																																																																																																																																																		
H7620	001	0	1	01	01	H7620_001_0	10	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7635	001	0	1	01	01	H7635_001_0	12	2				1	20	20	20	2				2		1	2	1		1250.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	6	Benefit covers 1 Bitewing X-Ray, 1 Full-Mouth X-Ray every 5 years, and Single X-Rays as needed.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	2	1	6	One procedure per tooth per lifetime.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Once every 60 months.	2				2				2	2																															2	2	1	6	Once every 60 months.	2				2				2	2	2	1				2				2				2	2																														
H7656	001	0	1	20	08	H7656_001_0	2																																																																																																																																																																																																																																																																																																		
H7656	002	0	1	20	08	H7656_002_0	2																																																																																																																																																																																																																																																																																																		
H7660	001	0	1	20	08	H7660_001_0	2																																																																																																																																																																																																																																																																																																		
H7660	002	0	1	20	08	H7660_002_0	2																																																																																																																																																																																																																																																																																																		
H7670	001	0	1	01	01	H7670_001_0	7	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	1	2		1000.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																															2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2
H7670	002	0	1	01	01	H7670_002_0	7	2				2				1	15.00	15.00	15.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	1	2		1500.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																															2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2
H7678	006	1	1	01	01	H7678_006_1	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H7678	006	2	1	01	01	H7678_006_2	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H7680	001	0	1	01	01	H7680_001_0	7	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	002	0	1	01	01	H7680_002_0	7	2				2				2				2		2	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	007	0	1	01	01	H7680_007_0	5	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7680	009	0	1	01	01	H7680_009_0	6	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	011	0	1	01	01	H7680_011_0	6	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	012	0	1	01	01	H7680_012_0	6	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	014	0	1	01	01	H7680_014_0	5	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	015	0	1	01	01	H7680_015_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	016	0	1	01	01	H7680_016_0	5	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	017	0	1	01	01	H7680_017_0	5	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	2				2				2	2																															2	2	1	6	Once per arch per 5 years	2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7680	018	0	1	01	01	H7680_018_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	019	0	1	02	01	H7680_019_0	6	2				2				2				2		2	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	020	0	1	01	01	H7680_020_0	5	2				2				2				2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		3		10	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	2	3		3		10	50	2				2	2	2	2	1	6	Either once per arch per 5 years or once per arch per year depending on service	3		10	50	2				2	2																															2	2	1	6	Once per arch per 5 years	3		10	50	2				2	2	2	1				3		10	50	2				2	2																2	1				3		10	50	2				2	2
H7680	801	0	1	01	01	H7680_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7710	001	0	1	01	01	H7710_001_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	1					2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 2 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2																																														2	1				2				2				2	2																														
H7710	002	0	1	01	01	H7710_002_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Panoramic and full mouth x-rays once every 5 years, bitewing, periapical and occlusal x-rays once every 6 months.	2				2				2	2																2	2	4	3		2				2				2	2																															1	2		1500.00	3		2					2		2	2	1	6	Amalgam or resin fillings unlimited. Crowns limited to 1 per year, 1 crown in 5 years per tooth.	2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	2		2				2				2	2	2	2	1	6	Dentures are covered one per arch every 5 years, including a full denture, a partial denture or an immediate denture and are not applied to the comprehensive maximum plan coverage amount.	2				2				2	2																																														2	1				2				2				2	2																														
H7725	001	0	1	20	08	H7725_001_0	2																																																																																																																																																																																																																																																																																																		
H7725	002	0	1	20	08	H7725_002_0	2																																																																																																																																																																																																																																																																																																		
H7766	001	0	1	04	01	H7766_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7766	002	0	1	04	01	H7766_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7766	004	0	1	04	01	H7766_004_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	005	0	1	04	01	H7766_005_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7766	006	0	1	04	01	H7766_006_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7766	012	0	1	04	01	H7766_012_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	013	0	1	04	01	H7766_013_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	014	0	1	04	01	H7766_014_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7766	015	0	1	04	01	H7766_015_0	6	2				1	30	30	30	2				2		1	2	1	2	3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7777	001	0	1	20	08	H7777_001_0	2																																																																																																																																																																																																																																																																																																		
H7777	002	0	1	20	08	H7777_002_0	1																																																																																																																																																																																																																																																																																																		
H7779	001	0	1	01	01	H7779_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7787	001	0	1	04	01	H7787_001_0	4	2				2				1	25.00	25.00	25.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7787	801	0	1	04	01	H7787_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	802	0	1	04	01	H7787_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	803	0	1	04	01	H7787_803_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	804	0	1	04	01	H7787_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	805	0	1	04	01	H7787_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	806	0	1	04	01	H7787_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	807	0	1	04	01	H7787_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	808	0	1	04	01	H7787_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	809	0	1	04	01	H7787_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	810	0	1	04	01	H7787_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	811	0	1	04	01	H7787_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	812	0	1	04	01	H7787_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	813	0	1	04	01	H7787_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	814	0	1	04	01	H7787_814_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	815	0	1	04	01	H7787_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	816	0	1	04	01	H7787_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	817	0	1	04	01	H7787_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	818	0	1	04	01	H7787_818_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	819	0	1	04	01	H7787_819_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	820	0	1	04	01	H7787_820_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	821	0	1	04	01	H7787_821_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	822	0	1	04	01	H7787_822_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	823	0	1	04	01	H7787_823_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	824	0	1	04	01	H7787_824_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	825	0	1	04	01	H7787_825_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	826	0	1	04	01	H7787_826_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7787	827	0	1	04	01	H7787_827_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7813	001	0	1	01	01	H7813_001_0	3	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	5		2				2				2	2	2	2	1	4		2				2				2	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				2	2
H7831	001	0	1	20	08	H7831_001_0	2																																																																																																																																																																																																																																																																																																		
H7831	002	0	1	20	08	H7831_002_0	2																																																																																																																																																																																																																																																																																																		
H7849	002	0	1	04	01	H7849_002_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	015	0	1	04	01	H7849_015_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	024	0	1	04	01	H7849_024_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	029	0	1	04	01	H7849_029_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	059	0	1	04	01	H7849_059_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	065	0	1	04	01	H7849_065_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	070	0	1	04	01	H7849_070_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	077	0	1	04	01	H7849_077_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1050.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	080	0	1	04	01	H7849_080_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	088	0	1	04	01	H7849_088_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	102	1	1	04	01	H7849_102_1	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	102	2	1	04	01	H7849_102_2	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	102	3	1	04	01	H7849_102_3	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	106	0	1	04	01	H7849_106_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	1	1	04	01	H7849_113_1	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	900.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	2	1	04	01	H7849_113_2	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	3	1	04	01	H7849_113_3	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	113	4	1	04	01	H7849_113_4	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	114	0	1	04	01	H7849_114_0	6	2				2				1	25.00	25.00	25.00	2		1	2																																																																																																																																																																																																																																																																																		
H7849	135	0	1	04	01	H7849_135_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1	2	1700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	136	1	1	04	01	H7849_136_1	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	136	2	1	04	01	H7849_136_2	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	136	3	1	04	01	H7849_136_3	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	1400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	142	0	1	04	01	H7849_142_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	143	0	1	04	01	H7849_143_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	144	0	1	04	01	H7849_144_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	145	0	1	04	01	H7849_145_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	146	0	1	04	01	H7849_146_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	147	0	1	04	01	H7849_147_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	148	0	1	04	01	H7849_148_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	149	0	1	04	01	H7849_149_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	150	0	1	04	01	H7849_150_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	151	0	1	04	01	H7849_151_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	152	0	1	04	01	H7849_152_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	153	0	1	04	01	H7849_153_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	154	0	1	04	01	H7849_154_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	155	0	1	04	01	H7849_155_0	5	2				2				1	40.00	40.00	40.00	2		1	2	1	2	550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H7849	835	0	1	04	01	H7849_835_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7849	836	0	1	04	01	H7849_836_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H7855	001	0	1	20	08	H7855_001_0	2																																																																																																																																																																																																																																																																																																		
H7855	002	0	1	20	08	H7855_002_0	2																																																																																																																																																																																																																																																																																																		
H7917	009	0	1	04	01	H7917_009_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	010	0	1	04	01	H7917_010_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	011	0	1	04	01	H7917_011_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	012	0	1	04	01	H7917_012_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	013	0	1	04	01	H7917_013_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	014	0	1	04	01	H7917_014_0	7	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	015	0	1	04	01	H7917_015_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2750.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	030	0	1	04	01	H7917_030_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	031	0	1	04	01	H7917_031_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2750.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	032	0	1	04	01	H7917_032_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	033	0	1	04	01	H7917_033_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	038	0	1	04	01	H7917_038_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2250.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	039	0	1	04	01	H7917_039_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	040	0	1	04	01	H7917_040_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	041	0	1	04	01	H7917_041_0	8	2				2				1	25.00	25.00	25.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	20	20	20	2				1	2																															2	2	1	6	1 per 60 months	1	20	20	20	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	044	0	1	04	01	H7917_044_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	50	50	50	2				1	2																															2	2	1	6	1 per 60 months	1	50	50	50	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	045	0	1	04	01	H7917_045_0	5	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	50	50	50	2				1	2																															2	2	1	6	1 per 60 months	1	50	50	50	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	046	0	1	04	01	H7917_046_0	5	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Covered Preventative X-rays 1 per 12 monthsCovered Diagnostic X-ray 1 per 36 monthsOther limitations apply.	2				2				2	2	2	1				2				2				1	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				1	2	2	1				2				2				2	2	1	1					2					2		2	2	1	6	Fillings (limited to 1 per tooth surface per year)Crowns (limited to 1 per tooth per 5 years)Bridges (limited to 1 per 5 years)Denture repair and adjustments (limited to 1 per 36 months)	1	20	20	20	2				1	2	2	2	1	6	1 per tooth per 60 months	2				2				1	2	2	2	1	1		2				2				1	2	2	2	1	6	1 per 60 months	1	50	50	50	2				1	2																															2	2	1	6	1 per 60 months	1	50	50	50	2				1	2	2	1				1	20	20	20	2				1	2																														
H7917	801	0	1	04	01	H7917_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7917	802	0	1	04	01	H7917_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7917	803	0	1	04	01	H7917_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H7980	001	0	1	04	01	H7980_001_0	8	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	1 every 3 years per tooth on unrestored perm molars	2				2				2	2	1	2	2	2000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																															2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H7993	001	0	1	01	01	H7993_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	002	0	1	01	01	H7993_002_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	003	0	1	01	01	H7993_003_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	004	0	1	01	01	H7993_004_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	006	0	1	01	01	H7993_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	007	0	1	01	01	H7993_007_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	008	0	1	01	01	H7993_008_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	010	0	1	01	01	H7993_010_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	012	0	1	01	01	H7993_012_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	014	0	1	01	01	H7993_014_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	015	0	1	01	01	H7993_015_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	017	0	1	01	01	H7993_017_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	019	0	1	01	01	H7993_019_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	020	0	1	01	01	H7993_020_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	021	0	1	01	01	H7993_021_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	023	0	1	01	01	H7993_023_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	024	0	1	01	01	H7993_024_0	5	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	027	0	1	01	01	H7993_027_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	028	0	1	01	01	H7993_028_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	029	0	1	01	01	H7993_029_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	030	0	1	01	01	H7993_030_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	031	0	1	01	01	H7993_031_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	033	0	1	01	01	H7993_033_0	5	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	034	0	1	01	01	H7993_034_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	035	0	1	01	01	H7993_035_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	036	0	1	01	01	H7993_036_0	6	2				1	30	30	30	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	037	0	1	01	01	H7993_037_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	038	0	1	01	01	H7993_038_0	5	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	040	0	1	01	01	H7993_040_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	041	0	1	01	01	H7993_041_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H7993	046	0	1	01	01	H7993_046_0	5	2				2				1	25.00	25.00	25.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H7993	048	0	1	01	01	H7993_048_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8003	001	0	1	04	01	H8003_001_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	2500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	002	0	1	04	01	H8003_002_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	2500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	003	0	1	04	01	H8003_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	2500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	004	0	1	04	01	H8003_004_0	4	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	1500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	005	0	1	04	01	H8003_005_0	4	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	1500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	006	0	1	04	01	H8003_006_0	5	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	1500.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	007	0	1	04	01	H8003_007_0	4	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	1	2	2	3000.00	3		2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8003	801	0	1	04	01	H8003_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8003	802	0	1	04	01	H8003_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8003	803	0	1	04	01	H8003_803_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8003	804	0	1	04	01	H8003_804_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8010	002	0	1	01	01	H8010_002_0	7	2				2				1	10.00	10.00	10.00	2		2	2	1		1250.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2	2	2	1	3		2				1	30.00	30.00	30.00	2	2																2	2	1	3		2				1	30.00	30.00	30.00	2	2
H8010	003	0	1	01	01	H8010_003_0	6	2				2				2				2		2	2	1		2000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		1	50	50	50	2				2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2	2	2	1	3		2				1	20.00	20.00	20.00	2	2																2	2	1	3		2				1	20.00	20.00	20.00	2	2
H8048	001	0	1	20	08	H8048_001_0	1																																																																																																																																																																																																																																																																																																		
H8048	002	0	1	20	08	H8048_002_0	1																																																																																																																																																																																																																																																																																																		
H8051	001	0	1	01	01	H8051_001_0	10	2				1	20	20	20	2				2		1	2	2					2														2		2	2	1	3		2				2				2	2																																																																												2						2					2		2	2	1	6	Restorative Crowns - 1 per tooth every 7 calendar years	2				2				1	2																															2	2	1	6	Prosthodontics - Rebases for full or partial dentures covered once every 2 calendar years. Replacement of all teeth & acrylic on cast metal frame covered once every 3 calendar years	2				2				1	2																															2	2	1	6	Fixed partial dentures (bridges) - 1 per tooth every 7 calendar years	2				2				1	2																															2	2	1	6	One consultation is covered every calendar year	2				2				1	2
H8067	001	0	1	01	01	H8067_001_0	4	2				1	20	20	20	2				2		2	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H8067	003	0	1	01	01	H8067_003_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H8067	004	0	1	01	01	H8067_004_0	4	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H8082	001	0	1	20	08	H8082_001_0	2																																																																																																																																																																																																																																																																																																		
H8082	002	0	1	20	08	H8082_002_0	2																																																																																																																																																																																																																																																																																																		
H8093	001	0	1	01	01	H8093_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8093	002	0	1	01	01	H8093_002_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8095	801	0	1	01	01	H8095_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8095	802	0	1	01	01	H8095_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8095	807	0	1	02	01	H8095_807_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8095	808	0	1	02	01	H8095_808_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8096	001	0	1	20	08	H8096_001_0	2																																																																																																																																																																																																																																																																																																		
H8096	002	0	1	20	08	H8096_002_0	2																																																																																																																																																																																																																																																																																																		
H8099	001	0	1	20	08	H8099_001_0	2																																																																																																																																																																																																																																																																																																		
H8099	002	0	1	20	08	H8099_002_0	2																																																																																																																																																																																																																																																																																																		
H8121	801	0	1	04	01	H8121_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8133	001	0	1	01	01	H8133_001_0	7	2				2				1	35.00	35.00	35.00	2		2	2																																																																																																																																																																																																																																																																																		
H8133	005	0	1	01	01	H8133_005_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8142	001	0	1	02	01	H8142_001_0	11	2				2				2				2		2	2	1		3500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	3		0	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		0	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		0	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	002	0	1	02	01	H8142_002_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	003	0	1	02	01	H8142_003_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	004	0	1	02	01	H8142_004_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	005	0	1	02	01	H8142_005_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	006	0	1	02	01	H8142_006_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	007	0	1	02	01	H8142_007_0	9	2				2				2				2		2	2	1		3500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	3		0	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	3		0	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	3		0	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	008	0	1	02	01	H8142_008_0	9	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	009	0	1	02	01	H8142_009_0	11	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	010	0	1	02	01	H8142_010_0	9	2				2				2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Full mouth X-rays once every 60 months.  Bitewing X-rays are covered once every 12 months.	2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																2	2	1	6	Labs and other tests (e.g., pulp vitality tests) as needed.	2				2				2	2	1	1					2					2		2	2	1	6	Resin and amalgam fillings are covered once per surface per tooth every 24 months.  Dentures once every 5 years. Crowns/inlays/onlays/bridges and implants are covered once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Root canals are covered once per tooth per lifetime.  Pulp capping, as needed.  Pulpal therapy, apexification, and calcification once per lifetime per tooth.	1	50	50	50	2				2	2	2	2	1	6	Periodontal surgery once per quadrant every 36 months.  Periodontal maintenance up to two times every calendar year in combination with Prophylaxis cleanings.  Scaling and root planing once per quadrant every 24 months.	1	50	50	50	2				2	2	2	2	1	6	Dentures through Prosthodontist once every 5 calendar years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.	1	50	50	50	2				2	2																2	2	1	6	Implants are covered once per tooth position every 10 calendar years.  Implant repairs and supported prosthetics once per tooth every 10 calendar years.	1	50	50	50	2				2	2	2	2	1	6	Dentures once every 5 years.  Denture adjustments once every 6 months.  Dental rebases or relines once every 36 months.  Tissue conditioning once every 36 months.  Bridges once every 10 years.	1	50	50	50	2				2	2	2	2	1	6	Oral surgery for simple and surgical extractions.  Includes one brush biopsy every 24 months. Alveoloplasty in conjunction with extractions are included once per quadrant per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Consultations one every 12 months. General anesthesia and IV sedation, if medically/dentally necessary.  Diagnostic casts as needed.	1	50	50	50	2				2	2
H8142	801	0	1	02	01	H8142_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8142	802	0	1	02	01	H8142_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8142	803	0	1	02	01	H8142_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8142	804	0	1	02	01	H8142_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8145	004	0	1	09	04	H8145_004_0	4	2				2				1	40.00	40.00	40.00	2				1	2	2000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00			2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00																																	2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00			2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00		
H8145	006	0	1	09	04	H8145_006_0	3	2				2				1	55.00	55.00	55.00	2				1	2	3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00			2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00																																	2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00			2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00		
H8145	032	0	1	09	04	H8145_032_0	3	2				2				1	40.00	40.00	40.00	2				1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	1		2				1	0.00	0.00	0.00																																																2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00			2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00		
H8145	042	0	1	09	04	H8145_042_0	7	2				2				1	30.00	30.00	30.00	2				1	2	2500.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00																		2	1				2				1	0.00	0.00	0.00			1	1					2					2		2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00																																	2	1				2				1	0.00	0.00	0.00			2	1				2				1	0.00	0.00	0.00																		2	1				2				1	0.00	0.00	0.00		
H8145	052	0	1	09	04	H8145_052_0	3	2				2				1	45.00	45.00	45.00	2				1	2	1750.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	1		2				1	0.00	0.00	0.00																																																2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00			2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00		
H8145	055	0	1	09	04	H8145_055_0	2	2				2				1	30.00	30.00	30.00	2				2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00			4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			4	2	1	1		2				1	0.00	0.00	0.00			4	2	2	3		2				1	0.00	0.00	0.00																		4	2	4	3		2				1	0.00	0.00	0.00			2						2					2		3															3															3															3																																													3															3																														4	1				2				1	0.00	0.00	0.00		
H8145	069	0	1	09	04	H8145_069_0	3	2				2				1	20.00	20.00	20.00	2				1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	1		2				1	0.00	0.00	0.00																																																2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00			2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00		
H8145	084	0	1	09	04	H8145_084_0	3	2				2				1	40.00	40.00	40.00	2				1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	1		2				1	0.00	0.00	0.00																																																2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00			2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00		
H8145	091	0	1	09	04	H8145_091_0	4	2				2				1	35.00	35.00	35.00	2				1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	1		2				1	0.00	0.00	0.00																																																2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00			2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00		
H8145	126	0	1	09	04	H8145_126_0	4	2				2				1	40.00	40.00	40.00	2				1	2	3500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00			2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			2	2	1	1		2				1	0.00	0.00	0.00			2	2	2	3		2				1	0.00	0.00	0.00																		2	2	4	3		2				1	0.00	0.00	0.00			1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00			2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00			2	2	2	1		2				1	0.00	0.00	0.00			2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00																																	2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00			2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00																		2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00		
H8145	163	0	1	09	04	H8145_163_0	2	2				2				1	0.00	0.00	0.00	2				2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00			4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00			4	2	1	1		2				1	0.00	0.00	0.00			4	2	2	3		2				1	0.00	0.00	0.00																		4	2	4	3		2				1	0.00	0.00	0.00			2						2					2		3															3															3															3																																													3															3																														4	1				2				1	0.00	0.00	0.00		
H8166	003	0	1	04	01	H8166_003_0	4	2				2				1	10.00	10.00	10.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	40	40	40	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	40	40	40	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	40	40	40	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	40	40	40	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	40	40	40	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	40	40	40	2				2	2																2	2	2	3		3		0	40	2				2	2
H8166	005	0	1	04	01	H8166_005_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H8166	006	0	1	04	01	H8166_006_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	2		1	50	50	50	2				2	2	2	2	1	6	Endodontic Services include Endodontic Therapy (root canal), Root Canal retreatment are limited to one per tooth per lifetime.	1	50	50	50	2				2	2	2	2	2	6	Periodontal cleaning limited to 2 every year.  Scaling/root planing 1 every 36 months per area of mouth	1	50	50	50	2				2	2	2	2	1	6	Limited to one set of dentures or partials every 5 years.Relining and rebasing is eligible once in a 3 year period.	1	50	50	50	2				2	2																															2	2	1	6	Crowns, inlays, onlays and bridges are limited to one every 5 years	1	50	50	50	2				2	2	2	2	1	6	Exposure of unerupted tooth limited to one tooth per lifetime	1	50	50	50	2				2	2																2	2	2	3		3		0	50	2				2	2
H8166	007	0	1	04	01	H8166_007_0	5	2				2				1	55.00	55.00	55.00	2		2	2																																																																																																																																																																																																																																																																																		
H8166	801	0	1	04	01	H8166_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8166	802	0	1	04	01	H8166_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8166	803	0	1	04	01	H8166_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8166	804	0	1	04	01	H8166_804_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8173	001	0	1	01	01	H8173_001_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	005	0	1	01	01	H8173_005_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	007	0	1	01	01	H8173_007_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	011	0	1	01	01	H8173_011_0	6	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	2		1500.00	3		2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	013	0	1	01	01	H8173_013_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	014	0	1	01	01	H8173_014_0	6	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	2		3000.00	3		2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	016	0	1	01	01	H8173_016_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1		3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	019	0	1	01	01	H8173_019_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	020	0	1	01	01	H8173_020_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	021	0	1	01	01	H8173_021_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	022	0	1	01	01	H8173_022_0	6	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8173	023	0	1	01	01	H8173_023_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8173	024	0	1	01	01	H8173_024_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8173	025	0	1	01	01	H8173_025_0	6	2				1	30	30	30	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8173	027	0	1	01	01	H8173_027_0	6	2				1	30	30	30	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8176	004	1	1	01	01	H8176_004_1	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set full, partial, or immediate every 3 yrs	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8176	004	2	1	01	01	H8176_004_2	9	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set full, partial, or immediate every 3 yrs	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8181	001	0	1	04	01	H8181_001_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H8181	002	0	1	04	01	H8181_002_0	7	2				2				1	35.00	35.00	35.00	2		2	2	1	2	1200.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H8181	003	0	1	04	01	H8181_003_0	7	2				2				1	20.00	20.00	20.00	2		2	2	1	2	1700.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H8181	801	0	1	04	01	H8181_801_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8181	802	0	1	04	01	H8181_802_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8181	803	0	1	04	01	H8181_803_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8181	804	0	1	04	01	H8181_804_0	5	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8189	001	0	1	02	01	H8189_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2		2	2	1	6	3 crowns or bridge units per plan year, 1 per tooth every 7 plan years. Other restorative every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																2	2	2	6	per calendar year, and once per same tooth every 7 plan years; other implant every date of service to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	3	6	per plan year, and once per same tooth every 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H8189	007	0	1	02	01	H8189_007_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		5000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H8189	008	0	1	02	01	H8189_008_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H8211	001	0	1	04	01	H8211_001_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8211	005	0	1	04	01	H8211_005_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8211	006	0	1	04	01	H8211_006_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8211	007	0	1	04	01	H8211_007_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8211	009	0	1	04	01	H8211_009_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8211	010	0	1	04	01	H8211_010_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8211	011	0	1	04	01	H8211_011_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8211	012	0	1	04	01	H8211_012_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8212	001	0	1	01	01	H8212_001_0	9	2				2				2				2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	6	Periodicity varies by procedure.	2				2				2	2	1	2		3000.00	3		2					2		2	1				2				2				1	2	2	2	1	6	Endodontics: Service limitations apply. 1 per tooth per lifetime. Prior authorization required. Pre and post-op radiographs required.	2				2				1	2	2	2	1	6	Periodontics: Service limitations apply. Prior authorization required. Scaling and Root Planing - 1 per 24 mo. Per quadrant. Debridement once per year. Scaling in the presence of gingival inflammation once per year. Subject to the combined limit every year.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2	2	2	1	6	Periodicity varies by procedure, see full note below.	2				2				1	2																														
H8298	001	0	1	01	01	H8298_001_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8320	001	0	1	04	01	H8320_001_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8320	002	0	1	04	01	H8320_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8320	003	0	1	04	01	H8320_003_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8320	004	0	1	04	01	H8320_004_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8320	005	0	1	04	01	H8320_005_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8320	006	0	1	04	01	H8320_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8320	011	0	1	04	01	H8320_011_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	012	0	1	04	01	H8320_012_0	6	2				1	30	30	30	2				2		1	2	1	2	3500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	013	0	1	04	01	H8320_013_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8320	014	0	1	04	01	H8320_014_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8330	001	0	1	01	01	H8330_001_0	6	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	2	6	2 periodic or limited oral exams per year. 1 comprehensive and periodontal exam per year.	2				2				2	2	2	2	1	6	Intraoral, panoramic or tomosynthesis comprehensive exam every 36 months. 1 bitewing (1-4 images or tomosynthesis) per year. Cone beam CT (1 per 36 months).	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	5		2				2				2	2	2	2	1	6	1 application of caries per lifetime.	2				2				2	2	2						2					2		2	2	1	6	1 filling per calendar year, per tooth same surface.Crowns, core, post, pins covered once per tooth per 60 months.	2				2				2	2	2	2	1	6	Root canals, bone graft in conjunction with periradicular surgery, tissue regeneration; each covered once per lifetime, same tooth.	2				2				2	2	2	2	1	6	Periodontal scaling, root planing, & osseous surgery 1/36 mths per quadrant. Periodontal maint'ce 1/12 mths. Scaling in presence of generalized inflammation full mouth 2/12 mths. Bone replacement graft, first & each add'l site 1/lifetime same tooth. Guided tissue regen 1/lifetime same tooth.	2				2				2	2	2	2	1	6	Complete dentures covered once per 60 months. Partial dentures covered once per 84 months. Rebase or reline dentures covered once per 36 months.	2				2				2	2																															2	2	1	6	Pontics and retainers covered once per tooth, per 60 months.	2				2				2	2	2	2	1	6	Alveoloplasty covered once per 6 months per quadrant. Reimplantation or stabilization of tooth covered once per lifetime. Bone replacement graft covered 1 per lifetime per quadrant. Guided tissue regeneration resorbable barrier covered 1 per 60 months same tooth.	2				2				2	2																2	2	1	6	Consultation covered once per year per provider. Occlusal guards covered once per 36 months.	2				2				2	2
H8330	002	0	1	01	01	H8330_002_0	11	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	2	6	2 periodic or limited oral exams per year. 1 comprehensive and periodontal exam per year.	2				2				2	2	2	2	1	6	Intraoral, panoramic or tomosynthesis comprehensive exam every 36 months. 1 bitewing (1-4 images or tomosynthesis) per year. Cone beam CT (1 per 36 months).	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	5		2				2				2	2	2	2	1	6	1 application of caries per lifetime.	2				2				2	2	2						2					2		2	2	1	6	1 filling per calendar year, per tooth same surface.Crowns, core, post, pins covered once per tooth per 60 months.	2				2				2	2	2	2	1	6	Root canals, bone graft in conjunction with periradicular surgery, tissue regeneration; each covered once per lifetime, same tooth.	2				2				2	2	2	2	1	6	Periodontal scaling, root planing, & osseous surgery 1/36 mths per quadrant. Periodontal maint'ce 1/12 mths. Scaling in presence of generalized inflammation full mouth 2/12 mths. Bone replacement graft, first & each add'l site 1/lifetime same tooth. Guided tissue regen 1/lifetime same tooth.	2				2				2	2	2	2	1	6	Complete dentures covered once per 60 months. Partial dentures covered once per 84 months. Rebase or reline dentures covered once per 36 months.	2				2				2	2																															2	2	1	6	Pontics and retainers covered once per tooth, per 60 months.	2				2				2	2	2	2	1	6	Alveoloplasty covered once per 6 months per quadrant. Reimplantation or stabilization of tooth covered once per lifetime. Bone replacement graft covered 1 per lifetime per quadrant. Guided tissue regeneration resorbable barrier covered 1 per 60 months same tooth.	2				2				2	2																2	2	1	6	Consultation covered once per year per provider. Occlusal guards covered once per 36 months.	2				2				2	2
H8332	004	0	1	01	01	H8332_004_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1500.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H8332	801	0	1	01	01	H8332_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8379	001	0	1	01	01	H8379_001_0	6	2				3		0	35	2				2		1	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2																																2	2	2	3		2				2				2	2																																																													2	2	1	3		2				2				2	2																														
H8379	003	1	1	01	01	H8379_003_1	6	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																		
H8379	003	2	1	01	01	H8379_003_2	6	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																		
H8379	003	3	1	01	01	H8379_003_3	6	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																		
H8379	003	4	1	01	01	H8379_003_4	6	2				3		0	35	2				2		1	2																																																																																																																																																																																																																																																																																		
H8385	001	0	1	04	01	H8385_001_0	6	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One bitewing x-ray per year. One full mouth x-ray every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3		2					2		2	2	1	6	Fillings - 1 per 24 monthsCrowns - 1 per 5 years	2				2				2	2	2	2	1	6	Root canal therapy - 1 per lifetime	2				2				2	2	2	2	1	1		2				2				2	2																																																													2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal, or cartilage graft) - 1 per lifetime	2				2				2	2																														
H8385	002	0	1	04	01	H8385_002_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One bitewing x-ray per year. One full mouth x-ray every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1000.00	3		2					2		2	2	1	6	Fillings - 1 per 24 monthsCrowns - 1 per 5 years	2				2				2	2	2	2	1	6	Root canal therapy - 1 per lifetime	2				2				2	2	2	2	1	1		2				2				2	2																																																													2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal or cartilage graft) - 1 per lifetime	2				2				2	2																														
H8385	003	0	1	04	01	H8385_003_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	One bitewing x-ray per year. One full mouth x-ray every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	750.00	3		2					2		2	2	1	6	Fillings - 1 per 24 monthsCrowns - 1 per 5 years	2				2				2	2	2	2	1	6	Root canal therapy - 1 per lifetime	2				2				2	2	2	2	1	1		2				2				2	2																																																													2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal, or cartilage graft) - 1 per lifetime	2				2				2	2																														
H8385	004	0	1	04	01	H8385_004_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	750.00	3		2					2		2	2	1	6	Fillings - 1 per 24 monthsCrowns - 1 per 5 years	2				2				2	2	2	2	1	6	Root canal therapy - 1 per lifetime	2				2				2	2	2	2	1	1		2				2				2	2																																																													2	2	1	6	Oral surgery (alveoloplasty, osseous, osteoperiosteal or cartilage graft) - 1 per lifetime	2				2				2	2																														
H8390	015	0	1	01	01	H8390_015_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8390	017	0	1	01	01	H8390_017_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				1	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8421	001	0	1	20	08	H8421_001_0	2																																																																																																																																																																																																																																																																																																		
H8421	002	0	1	20	08	H8421_002_0	2																																																																																																																																																																																																																																																																																																		
H8424	001	0	1	20	08	H8424_001_0	2																																																																																																																																																																																																																																																																																																		
H8424	002	0	1	20	08	H8424_002_0	2																																																																																																																																																																																																																																																																																																		
H8432	009	0	1	01	01	H8432_009_0	4	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H8432	010	0	1	01	01	H8432_010_0	4	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H8432	011	0	1	01	01	H8432_011_0	4	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H8432	016	0	1	02	01	H8432_016_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		750.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8432	036	0	1	02	01	H8432_036_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1		1000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8432	040	0	1	02	01	H8432_040_0	7	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	4	2	1	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																		
H8432	041	0	1	01	01	H8432_041_0	6	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	3	6	For limited, Periodic and ComprehensiveLimited oral evaluation 2 every 12 monthsComprehensive oral evaluation 1 per lifetimeOral evaluation, problem focused 3 every 12 months, by reportPeriodic Oral evaluation 2 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral, complete series - 1 every 36 months.  Intraoral, periapical- 3 every 6 months; Intraoral, periapical 6 times every 12 monthsPanoramic Radiographic image- 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every six months.Unspecified preventive procedure, by report.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Amalgam / Resin based composites - 1 per tooth - every 24 monthsCrown services - 1 per tooth - every 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	details listed below	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch.	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	Implants are covered once per tooth per lifetime.  Implant scaling repair is covered once per 12 months.Implant replacements / rebond/ debridement are covered once per tooth 24 months.Implant abutments are covered once per tooth per 96 months. All implant services require prior authorization.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics -Once every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	1 per tooth per lifetime.  Other Oral and Maxillofacial Surgery by report	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Limited to members who are:Exhibit a sever physically handicapping malocclusion	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Office visit, observation - 4 every 12 monthsocclusal guard - 1 every 12 months	2				1	0.00	0.00	0.00	1	2
H8432	042	0	1	01	01	H8432_042_0	5	2				1	20	20	20	2				2		1	1	2					2				2					2					2		2	2	3	6	For limited, Periodic and ComprehensiveLimited oral evaluation 2 every 12 monthsComprehensive oral evaluation 1 per lifetimeOral evaluation, problem focused 3 every 12 months, by reportPeriodic Oral evaluation 2 every 6 months	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral, complete series - 1 every 36 months.  Intraoral, periapical- 3 every 6 months; Intraoral, periapical 6 times every 12 monthsPanoramic Radiographic image- 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Cone beam CT capture and interpretation - 1 every 60 months.	2				1	0.00	0.00	0.00	2	2	2	2	1	4		2				1	0.00	0.00	0.00	2	2																2	2	1	6	Tobacco counseling, control prevention oral disease - 1 every six months.Unspecified preventive procedure, by report.	2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Amalgam / Resin based composites - 1 per tooth - every 24 monthsCrown services - 1 per tooth - every 60 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontic Services - 1 per tooth, per lifetime	2				1	0.00	0.00	0.00	1	1	2	2	1	6	details listed below	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch.	2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	1	2	2	1	6	Implants are covered once per tooth per lifetime.  Implant scaling repair is covered once per 12 months.Implant replacements / rebond/ debridement are covered once per tooth 24 months.Implant abutments are covered once per tooth per 96 months. All implant services require prior authorization.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics -Once every 5 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	1 per tooth per lifetime.  Other Oral and Maxillofacial Surgery by report	2				1	0.00	0.00	0.00	1	1	2	2	1	6	Limited to members who are:Exhibit a sever physically handicapping malocclusion	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Office visit, observation - 4 every 12 monthsocclusal guard - 1 every 12 months	2				1	0.00	0.00	0.00	1	2
H8432	804	0	1	01	01	H8432_804_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8432	805	0	1	01	01	H8432_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8432	806	0	2	01	01	H8432_806_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8432	811	0	2	01	01	H8432_811_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8432	813	0	1	01	01	H8432_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8432	816	0	2	01	01	H8432_816_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8457	001	0	1	01	01	H8457_001_0	4	2				1	20	20	20	2				2		1	2	1		2850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8481	001	0	1	04	01	H8481_001_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	The plan provides one set of bitewing X-rays every year. The plan provides one set of full mouth X-rays every 5 years.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2	2	2	7	6	Deep Cleaning/Root Planing: 1 per quadrant every 24 months (Up to 4 total for 4 quadrants in mouth). Full Mouth Debridement: 1 every 3 calendar yearsTherapeutic Cleaning – Gum Inflammation: 2 per calendar year. The 2 cleaning service total is shared with the 16b4 benefit.	2				1	0.00	0.00	0.00	2	2	2	2	10	6	Immediate upper complete denture - 1 per lifetimeImmediate lower complete denture - 1 /lifetimeUpper partial/denture - 1  every 5 yearsLower partial/denture - 1 every 5 yearsUpper partial/denture adjustments /repairs - 2 per calendar yearLower partial/denture adjustments /repairs - 2 per year	2				1	0.00	0.00	0.00	2	2																																														2	2	5	6	Extractions (simple & surgical): 4 per calendar year. Removal of Impacted Tooth: 1 per tooth per lifetime	2				1	0.00	0.00	0.00	2	2																														
H8492	001	0	1	01	01	H8492_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8547	001	0	1	01	01	H8547_001_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8552	028	0	1	04	01	H8552_028_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8554	001	0	1	01	01	H8554_001_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8554	003	0	1	01	01	H8554_003_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		4000.00	3		2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8578	001	0	1	01	01	H8578_001_0	5	2				2				3		30.00	200.00	2		1	2	1		1040.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	003	0	1	01	01	H8578_003_0	4	2				2				3		20.00	200.00	2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	004	0	1	01	01	H8578_004_0	5	2				2				3		40.00	300.00	2		1	2	1		840.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	009	0	1	01	01	H8578_009_0	4	2				2				3		40.00	450.00	2		1	2	1		1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	012	0	1	01	01	H8578_012_0	6	2				2				3		50.00	450.00	2		1	2	1		775.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H8578	801	0	1	02	01	H8578_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8578	802	0	1	02	01	H8578_802_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8578	803	0	1	02	01	H8578_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8597	001	0	1	01	01	H8597_001_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	002	0	1	01	01	H8597_002_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8597	003	0	1	01	01	H8597_003_0	3	2				1	20	20	20	2				2		1	2	1		1000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8604	011	0	1	04	01	H8604_011_0	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H8604	014	1	1	04	01	H8604_014_1	5	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		4	2	1	6	One Filling per tooth every three years.One Crown per tooth every five years.	2				2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	2				2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.Periodontal maintenance - two every calendar year.Full mouth debridement - one every three calendar years.	2				2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	2				2				2	2	4	1				2				2				2	2																														
H8604	014	2	1	04	01	H8604_014_2	5	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		4	2	1	6	One Filling per tooth every three years.One Crown per tooth every five years.	2				2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	2				2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.Periodontal maintenance - two every calendar year.Full mouth debridement - one every three calendar years.	2				2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															4	2	1	6	One crown per tooth every five calendar years.	2				2				2	2	4	1				2				2				2	2																														
H8604	015	0	1	04	01	H8604_015_0	6	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	3	3		2				2				2	2	2	2	1	6	One set of bitewing x-rays every year. One panoramic radiographic image (x-ray) every three years.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		4	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	2				2				2	2	4	2	1	6	One endodontic therapy/ (I.E. root canal) per tooth every calendar year.	2				2				2	2	4	2	1	6	Scaling and root planing - one per site every three calendar years.  Periodontal maintenance - two every calendar year.  Full mouth debridement - one every three calendar years.	2				2				2	2	4	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	2				2				2	2																															4	2	1	6	One crown per tooth every five calendar years	2				2				2	2	4	1				2				2				2	2																														
H8604	801	0	1	04	01	H8604_801_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8614	001	0	1	20	08	H8614_001_0	2																																																																																																																																																																																																																																																																																																		
H8614	002	0	1	20	08	H8614_002_0	2																																																																																																																																																																																																																																																																																																		
H8634	003	0	1	04	01	H8634_003_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	004	0	1	04	01	H8634_004_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	008	0	1	04	01	H8634_008_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	009	0	1	04	01	H8634_009_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8634	010	0	1	04	01	H8634_010_0	7	2				2				1	40.00	40.00	40.00	2		2	2																																																																																																																																																																																																																																																																																		
H8634	012	0	1	04	01	H8634_012_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	018	0	1	04	01	H8634_018_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	019	0	1	04	01	H8634_019_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	021	0	1	04	01	H8634_021_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	022	0	1	04	01	H8634_022_0	9	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8634	023	0	1	04	01	H8634_023_0	9	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8634	024	0	1	04	01	H8634_024_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	3000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	025	0	1	04	01	H8634_025_0	8	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8634	026	0	1	04	01	H8634_026_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	027	0	1	04	01	H8634_027_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	028	0	1	04	01	H8634_028_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H8634	029	0	1	04	01	H8634_029_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	4000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	030	0	1	04	01	H8634_030_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	031	0	1	04	01	H8634_031_0	7	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8634	032	0	1	04	01	H8634_032_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	750.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H8634	033	0	1	04	01	H8634_033_0	7	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H8634	801	0	1	04	01	H8634_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	803	0	1	04	01	H8634_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	805	0	1	04	01	H8634_805_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	807	0	1	04	01	H8634_807_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	809	0	1	04	01	H8634_809_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	811	0	1	04	01	H8634_811_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	813	0	1	04	01	H8634_813_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	815	0	1	04	01	H8634_815_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	817	0	1	04	01	H8634_817_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	819	0	1	04	01	H8634_819_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	820	0	1	04	01	H8634_820_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	821	0	1	04	01	H8634_821_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	822	0	1	04	01	H8634_822_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	823	0	1	04	01	H8634_823_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8634	824	0	1	04	01	H8634_824_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8649	010	0	1	01	01	H8649_010_0	2	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H8649	013	0	1	01	01	H8649_013_0	2	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	20	20	20	2				2	2	2	2	4	6	See Notes	3		20	50	2				2	2	2	2	2	6	See Notes	1	50	50	50	2				2	2																															2	2	1	6	See Notes	1	50	50	50	2				2	2	2	2	1	6	See Notes	3		20	50	2				2	2																2	1				3		20	50	2				2	2
H8649	801	0	1	01	01	H8649_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8649	803	0	1	01	01	H8649_803_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8655	004	0	1	20	08	H8655_004_0	2																																																																																																																																																																																																																																																																																																		
H8655	005	0	1	20	08	H8655_005_0	2																																																																																																																																																																																																																																																																																																		
H8711	801	0	1	04	01	H8711_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8764	001	0	1	01	01	H8764_001_0	5	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2																																																																																																																																																																																																	
H8764	002	0	1	02	01	H8764_002_0	5	2				2				1	20.00	20.00	20.00	2		1	2																																																																																																																																																																																																																																																																																		
H8764	003	0	1	01	01	H8764_003_0	6	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																		
H8764	004	0	1	01	01	H8764_004_0	7	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																		
H8764	801	0	1	02	01	H8764_801_0	3	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	005	0	1	04	01	H8768_005_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	007	0	1	04	01	H8768_007_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	008	0	1	04	01	H8768_008_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	009	0	1	04	01	H8768_009_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	010	0	1	04	01	H8768_010_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	011	0	1	04	01	H8768_011_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	013	0	1	04	01	H8768_013_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	016	0	1	04	01	H8768_016_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	017	1	1	04	01	H8768_017_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	017	2	1	04	01	H8768_017_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	018	0	1	04	01	H8768_018_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	019	0	1	04	01	H8768_019_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	020	0	1	04	01	H8768_020_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	021	0	1	04	01	H8768_021_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	022	0	1	04	01	H8768_022_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	023	0	1	04	01	H8768_023_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	024	0	1	04	01	H8768_024_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	025	0	1	04	01	H8768_025_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	026	0	1	04	01	H8768_026_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	027	0	1	04	01	H8768_027_0	4	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	028	0	1	04	01	H8768_028_0	3	2				1	20	20	20	2				2		1	2	1	2	1000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	030	0	1	04	01	H8768_030_0	4	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	031	0	1	04	01	H8768_031_0	3	2				1	20	20	20	2				2		1	2	1	2	5000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	034	0	1	04	01	H8768_034_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	035	0	1	04	01	H8768_035_0	4	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	037	1	1	04	01	H8768_037_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	037	2	1	04	01	H8768_037_2	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	039	0	1	04	01	H8768_039_0	5	2				1	20	20	20	2				2		1	2	1	2	2500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	040	0	1	04	01	H8768_040_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	045	0	1	04	01	H8768_045_0	3	2				1	20	20	20	2				2		1	2	1	2	2000.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	046	0	1	04	01	H8768_046_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	048	0	1	04	01	H8768_048_0	3	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2
H8768	055	1	1	04	01	H8768_055_1	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	055	2	1	04	01	H8768_055_2	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	058	0	1	04	01	H8768_058_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	059	0	1	04	01	H8768_059_0	3	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H8768	061	0	1	04	01	H8768_061_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	062	0	1	04	01	H8768_062_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8768	063	0	1	04	01	H8768_063_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
H8769	001	0	1	20	08	H8769_001_0	2																																																																																																																																																																																																																																																																																																		
H8769	002	0	1	20	08	H8769_002_0	2																																																																																																																																																																																																																																																																																																		
H8777	001	0	1	20	08	H8777_001_0	2																																																																																																																																																																																																																																																																																																		
H8777	002	0	1	20	08	H8777_002_0	2																																																																																																																																																																																																																																																																																																		
H8794	001	0	1	01	01	H8794_001_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	002	0	1	01	01	H8794_002_0	7	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	006	0	1	01	01	H8794_006_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	007	0	1	01	01	H8794_007_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	009	0	1	01	01	H8794_009_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	010	0	1	01	01	H8794_010_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	011	0	1	01	01	H8794_011_0	7	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	016	0	1	01	01	H8794_016_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	017	0	1	01	01	H8794_017_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	018	0	1	01	01	H8794_018_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	019	0	1	01	01	H8794_019_0	5	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	020	0	1	01	01	H8794_020_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	021	0	1	01	01	H8794_021_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	022	0	1	01	01	H8794_022_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	023	0	1	01	01	H8794_023_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	024	0	1	01	01	H8794_024_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8794	025	0	1	01	01	H8794_025_0	6	2				2				1	0.00	0.00	0.00	2		1	1																																																																																																																																																																																																																																																																																		
H8797	001	0	1	01	01	H8797_001_0	6	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H8797	003	0	1	02	01	H8797_003_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		2500.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H8797	004	0	1	02	01	H8797_004_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3100.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H8800	001	0	1	20	08	H8800_001_0	2																																																																																																																																																																																																																																																																																																		
H8800	002	0	1	20	08	H8800_002_0	2																																																																																																																																																																																																																																																																																																		
H8811	001	0	1	20	08	H8811_001_0	2																																																																																																																																																																																																																																																																																																		
H8811	002	0	1	20	08	H8811_002_0	2																																																																																																																																																																																																																																																																																																		
H8832	001	0	1	04	01	H8832_001_0	7	2				2				2				2		1	2	1	2	1000.00	3		2				2					2					2		4	2	1	4		2				2				1	2	4	2	1	1		2				2				1	2																4	2	1	4		2				2				1	2	4	2	1	4		2				2				1	2																1	1					2					2		4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2	4	1				2				2				1	2																															4	1				2				2				1	2	4	1				2				2				1	2																														
H8832	002	0	1	04	01	H8832_002_0	7	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H8832	003	0	1	04	01	H8832_003_0	6	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2																1	2	2	300.00	5		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H8832	801	0	1	04	01	H8832_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H8832	802	0	1	04	01	H8832_802_0	2	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H8832	803	0	1	04	01	H8832_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H8832	804	0	1	04	01	H8832_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H8845	001	0	1	01	01	H8845_001_0	8	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8845	004	0	1	01	01	H8845_004_0	9	2				1	30	30	30	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		2000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8845	005	0	1	01	01	H8845_005_0	9	2				1	30	30	30	2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		1600.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8845	007	1	1	01	01	H8845_007_1	9	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H8845	007	2	1	01	01	H8845_007_2	9	2				2				1	25.00	25.00	25.00	2		2	2																																																																																																																																																																																																																																																																																		
H8849	001	0	1	02	01	H8849_001_0	6	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	003	0	1	02	01	H8849_003_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	005	0	1	02	01	H8849_005_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		2500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	006	0	1	02	01	H8849_006_0	6	2				2				1	20.00	20.00	20.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8849	009	0	1	02	01	H8849_009_0	5	2				2				1	20.00	20.00	20.00	2		1	2	1		3250.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H8849	010	1	1	01	01	H8849_010_1	7	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	010	2	1	01	01	H8849_010_2	7	2				1	20	20	20	2				2		1	2	1		5000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	010	4	1	01	01	H8849_010_4	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	010	5	1	01	01	H8849_010_5	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	011	1	1	01	01	H8849_011_1	7	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	011	2	1	01	01	H8849_011_2	7	2				1	20	20	20	2				2		1	2	1		3500.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	011	3	1	01	01	H8849_011_3	7	2				1	20	20	20	2				2		1	2	1		2750.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	011	4	1	01	01	H8849_011_4	7	2				1	20	20	20	2				2		1	2	1		2250.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8849	011	5	1	01	01	H8849_011_5	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2						2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H8854	002	0	1	01	01	H8854_002_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	1	6	Frequency varies based on service.	2				2				2	2	2	2	1	6	Bitewing: once every 12 months Periapical: once every 12 months Panoramic: once every 36 months Vertical bitewings: once every 36 months Intraoral Imaging: once every 36 months	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	2		3000.00	3		2					2		2	2	1	6	Restorative services: 1 per tooth, once every 24 monthsCrowns: once per tooth per 60 months	2				2				2	2	2	2	1	6	Endodontics: 1 per lifetime, per patient, per tooth Crowns: once per tooth per 60 months	2				2				2	2	2	2	1	6	Periodontics: once every 36 monthsPeriodontal maintenance: once every 3 months	2				2				2	2	2	2	1	6	Prosthodontics (dental plates: either upper, lower, or partial, or any combination thereof), once every 60 monthsFrequency varies depending on denture services.	2				2				2	2																																														2	2	1	6	Simple extractions: one per tooth per lifetime.	2				2				2	2																														
H8879	001	0	1	02	01	H8879_001_0	8	2				2				3		0.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H8889	001	0	1	04	01	H8889_001_0	5	2				2				3		0.00	50.00	2		2	2	1	2	700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	002	0	1	04	01	H8889_002_0	5	2				2				3		0.00	50.00	2		2	2	1	2	700.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	003	0	1	04	01	H8889_003_0	5	2				2				3		0.00	20.00	2		2	2	1	2	800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	004	0	1	04	01	H8889_004_0	5	2				2				3		0.00	45.00	2		2	2	1	2	400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	005	0	1	04	01	H8889_005_0	5	2				2				3		0.00	65.00	2		2	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	008	0	1	04	01	H8889_008_0	5	2				2				3		0.00	55.00	2		2	2	1	2	300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	009	0	1	04	01	H8889_009_0	5	2				2				3		0.00	50.00	2		2	2	1	2	800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	010	0	1	04	01	H8889_010_0	5	2				2				3		0.00	55.00	2		2	2	1	2	450.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	011	0	1	04	01	H8889_011_0	5	2				2				3		0.00	20.00	2		2	2	1	2	750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	012	0	1	04	01	H8889_012_0	5	2				2				3		0.00	50.00	2		2	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	013	0	1	04	01	H8889_013_0	5	2				2				3		0.00	15.00	2		2	2	1	2	800.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	014	0	1	04	01	H8889_014_0	5	2				2				3		0.00	60.00	2		2	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	015	0	1	04	01	H8889_015_0	5	2				2				3		0.00	50.00	2		2	2	1	2	500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	016	0	1	04	01	H8889_016_0	8	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8889	017	0	1	04	01	H8889_017_0	5	2				2				3		0.00	60.00	2		2	2	1	2	400.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	018	0	1	04	01	H8889_018_0	5	2				2				3		0.00	50.00	2		2	2	1	2	550.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8889	801	0	1	04	01	H8889_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H8894	001	0	1	01	01	H8894_001_0	6	2				1	20	20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8902	002	0	1	01	01	H8902_002_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3500.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H8902	009	0	1	01	01	H8902_009_0	7	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		4000.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H8902	010	0	1	01	01	H8902_010_0	6	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		3500.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H8902	011	0	1	01	01	H8902_011_0	7	2				2				2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		240.00	5		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H8902	801	0	1	01	01	H8902_801_0	4	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8902	802	0	1	01	01	H8902_802_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8902	803	0	1	01	01	H8902_803_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8902	804	0	1	01	01	H8902_804_0	5	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8908	001	0	1	02	01	H8908_001_0	2	2				2				1	60.00	60.00	60.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-1/tooth/lifetime, crown recement-1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H8908	004	0	1	02	01	H8908_004_0	3	2				2				1	40.00	40.00	40.00	2		1	2	1		2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H8908	005	0	1	01	01	H8908_005_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2																																																																																											2	1				2				1	0.00	0.00	0.00	1	2
H8908	006	0	1	01	01	H8908_006_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1		1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
H8908	007	0	1	01	01	H8908_007_0	3	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
H8908	801	0	1	01	01	H8908_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8908	802	0	1	01	01	H8908_802_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8908	804	0	1	01	01	H8908_804_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8908	805	0	1	01	01	H8908_805_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H8917	001	0	1	04	01	H8917_001_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8917	002	0	1	04	01	H8917_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H8917	005	0	1	04	01	H8917_005_0	6	2				2				1	50.00	50.00	50.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8917	006	0	1	04	01	H8917_006_0	6	2				1	30	30	30	2				2		1	2	1	2	2500.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H8928	001	0	1	01	01	H8928_001_0	7	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewings (one, two, three, four images), intraoral tomosynthesis (bitewing radiographic image): 1 per calendar year. Intraoral tomosynthesis (periapical radiographic image): 8 per calendar year.	2				2				2	2	2	2	1	1		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	Inlays, Onlays, Crowns including core buildup, pins, post and core-1 per tooth per 60 months	2				2				1	2	2	2	1	6	Root canal therapy, anterior, premolar, molar: 1 per tooth per lifetime.	2				2				1	2	2	2	1	6	Periodontal maintenance-2 per 12 months following periodontal therapyPeriodontal scaling and root planing-1 per quadrant per 24 monthsGingevectomy/gingivoplasty once per quadrant per 36 months.	2				2				1	2	2	2	1	6	Removable dentures (complete, partial, immediate): 1 per 60 months. Adjustments: 1 per 6 months. Repair, replace teeth: 3 per 60 months. Replace all teeth, rebase, reline, soft liner, metal substructure: 1 per 12 months.	2				2				1	2																2	2	1	6	Dental implants covered 1 every sixty months, per tooth per member. Limit of two implants per calendar year per member.	2				2				1	2	2	2	1	6	Fixed partial dentures:  Pontics (resin, base metal, noble metal, porcelain or titanium), inlays, onlays, crowns and retainers: 1 per tooth per 60 months.  Recement or re-bond fixed partial denture: once per 60 months.	2				2				1	2	2	1				2				2				1	2																2	1				2				2				2	2
H8947	001	1	1	04	01	H8947_001_1	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	001	2	1	04	01	H8947_001_2	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	001	3	1	04	01	H8947_001_3	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	4500.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	001	4	1	04	01	H8947_001_4	4	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	1	1	04	01	H8947_002_1	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	2	1	04	01	H8947_002_2	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	4000.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	3	1	04	01	H8947_002_3	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	5000.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8947	002	4	1	04	01	H8947_002_4	5	2				2				1	20.00	20.00	20.00	2		2	2	1	2	3500.00	3		2				2					2					2		2	2	2	6	2 oral exams, of any procedure type (periodic oral exam/comprehensive oral/periodontal evaluation) per calendar year. 1 exam for limited oral evaluation - problem focused for emergency diagnostic exam	2				2				2	2	2	2	1	6	1 proc code for full mouth or panoramic x-rays-every 5 calendar years. 1 set of bitewings per calendar year. 1 proc code for intraoral x-rays per calendar year.	2				2				2	2																2	2	2	6	2 procedure codes per calendar year for prophylaxis or 4 procedure codes per calendar year for periodontal maintenance following periodontal therapy	2				2				2	2	2	2	2	6	2 procedure codes per calendar year	2				2				2	2																1	1					2					2		2	2	1	6	Minor restorations are covered as either Amalgam and/or composite fillings, limited to 1 per tooth every 2 years; Other services limited to 1 procedure code per tooth every 5 years.	1	50	50	50	2				2	2	2	2	1	6	Root canal and retreatment of a root canal limited to 1 per tooth per lifetime.	1	50	50	50	2				2	2	2	2	1	6	Periodontal scaling and root planing covered per quadrant every 3 years. Full mouth debridement limited to 1 procedure every 3 years.	1	50	50	50	2				2	2	2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2																															2	2	1	6	Dentures are limited to 1 upper and 1 lower denture every 5 calendar years.	1	50	50	50	2				2	2	2	2	1	3		1	50	50	50	2				2	2																2	2	1	3		1	50	50	50	2				2	2
H8967	001	0	1	01	01	H8967_001_0	4	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Limit once every 5 years. Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex are payable once in a five year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	2				2				2	2																2	2	1	6	Implants are covered once per tooth per five-year period.	2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every 2 years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2
H8967	002	0	1	01	01	H8967_002_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Limit once every 5 years. Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex are payable once in a five year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	2		2000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years.	2				2				2	2																2	2	1	6	Implants are covered once per tooth per five year period.	2				2				2	2	2	2	1	6	A $1,500 limit may be used towards services related to the provision of dentures, covering one set of dentures every two years. Bridges are covered with a $500 limit once in a five year period.	2				2				2	2	2	2	1	3		2				2				2	2																2	2	1	3		2				2				2	2
H8967	003	0	1	01	01	H8967_003_0	5	2				1	20	20	20	2				2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Bitewing x-rays are covered once per calendar year. Full mouth x-rays (which include bitewing x-rays) or a panorex are covered once in a five year period.	2				2				2	2																2	2	2	3		2				2				2	2																															1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																																													2	1				2				2				2	2																2	1				2				2				2	2
H8982	001	0	1	20	08	H8982_001_0	2																																																																																																																																																																																																																																																																																																		
H8982	003	0	1	20	08	H8982_003_0	2																																																																																																																																																																																																																																																																																																		
H8992	001	0	1	20	08	H8992_001_0	2																																																																																																																																																																																																																																																																																																		
H8992	002	0	1	20	08	H8992_002_0	2																																																																																																																																																																																																																																																																																																		
H9001	030	15	1	01	01	H9001_030_15	6	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	030	16	1	01	01	H9001_030_16	6	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	030	18	1	01	01	H9001_030_18	6	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	15	1	01	01	H9001_031_15	6	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	16	1	01	01	H9001_031_16	6	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	031	18	1	01	01	H9001_031_18	6	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	038	0	1	01	01	H9001_038_0	6	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	039	0	1	01	01	H9001_039_0	4	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes below.	2				2				2	2	2	2	1	6	See notes below.	2				3		20.00	40.00	2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2						2					2		2	2	1	6	See notes below.	2				3		31.00	856.00	1	2	2	2	1	6	See notes below.	2				3		107.00	990.00	1	2	2	2	1	6	See notes below.	2				3		80.00	953.00	1	2	2	2	1	6	See notes below.	2				3		37.00	865.00	1	2																															2	2	1	6	See notes below.	2				3		76.00	860.00	1	2	2	2	1	6	See notes below.	2				3		77.00	667.00	1	2																2	2	1	3		2				3		39.00	157.00	1	2
H9001	803	0	1	01	01	H9001_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9003	001	0	1	02	01	H9003_001_0	4	2				2				1	20.00	20.00	20.00	2		1	1																																																																																																																																																																																																																																																																																		
H9003	006	0	1	02	01	H9003_006_0	4	2				2				1	30.00	30.00	30.00	2		1	1																																																																																																																																																																																																																																																																																		
H9003	008	0	1	02	01	H9003_008_0	4	2				2				1	30.00	30.00	30.00	2		1	1																																																																																																																																																																																																																																																																																		
H9003	009	0	1	02	01	H9003_009_0	4	2				2				1	45.00	45.00	45.00	2		1	1																																																																																																																																																																																																																																																																																		
H9003	801	0	1	01	01	H9003_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H9003	802	0	1	01	01	H9003_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H9042	004	0	1	04	01	H9042_004_0	7	2				2				2				2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years (Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period.) Posterior composite resin restorations are covered services.	2				2				2	2	2	1				2				2				2	2	2	2	2	6	Every year for perio maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	2				2				2	2	2	2	1	6	Every 5 years	2				2				2	2																2	2	1	6	1 implant per tooth per 5 year period	2				2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period	2				2				2	2	2	2	1	6	1 extraction per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H9042	007	0	1	04	01	H9042_007_0	7	2				2				2				2		2	2	1	2	2000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years (Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period.) Posterior composite resin restorations are covered services.	2				2				2	2	2	1				2				2				2	2	2	2	2	6	Every year for perio maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	2				2				2	2	2	2	1	6	Every 5 years	2				2				2	2																2	2	1	6	1 implant per tooth per 5 year period	2				2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period	2				2				2	2	2	2	1	6	1 extraction per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H9042	008	0	1	04	01	H9042_008_0	5	2				2				2				2		2	2	1	2	2500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	1					2					2		2	2	1	6	Every 5 years (Cast restorations (including crowns and onlays) and associated procedures (such as cores and substructures) on the same tooth are payable once in any five-year period.) Posterior composite resin restorations are covered services.	2				2				2	2	2	1				2				2				2	2	2	2	2	6	Every year for perio maintenance, but note that root planing and scaling is payable once per quadrant in 24 consecutive months. Full mouth debridement is a benefit once in a lifetime.	2				2				2	2	2	2	1	6	Every 5 years	2				2				2	2																2	2	1	6	1 implant per tooth per 5 year period	2				2				2	2	2	2	1	6	Bridges are covered once in a 5-year period. Relines & repairs to bridges covered once per tooth per 5-year period	2				2				2	2	2	2	1	6	1 extraction per tooth per lifetime	2				2				2	2																2	1				2				2				2	2
H9047	013	0	2	01	01	H9047_013_0	9	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	033	0	1	01	01	H9047_033_0	8	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	035	0	1	02	01	H9047_035_0	8	2				2				1	30.00	30.00	30.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	037	0	1	01	01	H9047_037_0	10	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	043	0	1	01	01	H9047_043_0	10	2				1	20	20	20	2				2		1	2	1		450.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9047	054	0	1	01	01	H9047_054_0	10	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	063	0	1	01	01	H9047_063_0	11	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	064	0	1	01	01	H9047_064_0	10	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	4	2	2	6	X-rays are covered as follows: Up to one bitewing series and up to one single x-ray per calendar year.	2				2				2	2	3													2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	3													2	2	2						2					2		3													2	2	3													2	2	4	2	2	3		2				2				2	2	3													2	2																															3													2	2	3													2	2																3													2	2
H9047	066	0	1	01	01	H9047_066_0	10	2				2				2				2		1	1	1		350.00	4		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9047	804	0	1	01	01	H9047_804_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9047	805	0	1	02	01	H9047_805_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9047	808	0	1	01	01	H9047_808_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9047	809	0	1	02	01	H9047_809_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9052	001	0	1	20	08	H9052_001_0	2																																																																																																																																																																																																																																																																																																		
H9052	002	0	1	20	08	H9052_002_0	2																																																																																																																																																																																																																																																																																																		
H9065	001	0	1	01	01	H9065_001_0	6	2				1	20	20	20	2				2		1	2	1		2000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9065	002	0	1	02	01	H9065_002_0	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H9065	003	0	1	02	01	H9065_003_0	6	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H9065	008	0	1	01	01	H9065_008_0	5	2				2				1	0.00	0.00	0.00	2		1	2																																																																																																																																																																																																																																																																																		
H9066	001	0	1	01	01	H9066_001_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H9066	002	0	1	01	01	H9066_002_0	6	2				2				2				2		2	2	2					2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H9066	003	0	1	01	01	H9066_003_0	7	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2						2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2
H9068	001	0	1	20	08	H9068_001_0	2																																																																																																																																																																																																																																																																																																		
H9068	002	0	1	20	08	H9068_002_0	2																																																																																																																																																																																																																																																																																																		
H9096	001	0	1	02	01	H9096_001_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1		600.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H9096	002	0	1	02	01	H9096_002_0	4	2				2				1	35.00	35.00	35.00	2		2	2	1		800.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H9096	004	0	1	01	01	H9096_004_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1		500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H9096	005	0	1	01	01	H9096_005_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H9096	010	0	1	02	01	H9096_010_0	4	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		2	1				1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2	2	2	1	6	Periodontal cleanings - twice per year.  Root planing/scaling - once per quadrant every 24 months.  Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2																2	2	1	6	Services are limited to once per tooth per 5-year period	1	50	50	50	2				2	2	2	2	1	6	Services are limited to once in a five-year period per tooth.	1	50	50	50	2				2	2	2	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H9096	801	0	1	01	01	H9096_801_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9096	802	0	1	01	01	H9096_802_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9096	803	0	1	01	01	H9096_803_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9096	804	0	1	02	01	H9096_804_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9096	805	0	1	02	01	H9096_805_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9096	806	0	1	02	01	H9096_806_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9147	001	0	1	02	01	H9147_001_0	11	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Endodontic Services are covered once per tooth per lifetime.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																																														2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2																2	2	1	6	See detailed benefit description below.	2				1	0.00	0.00	0.00	2	2
H9153	001	0	1	01	01	H9153_001_0	4	2				2				2				2		2	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																														
H9179	001	0	1	01	01	H9179_001_0	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9179	002	0	1	01	01	H9179_002_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2																																																																																											2	2	1	6	1 tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Frequency is unlimited or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9179	003	0	1	01	01	H9179_003_0	4	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9179	801	0	1	01	01	H9179_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9179	802	0	1	01	01	H9179_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9185	001	0	1	20	08	H9185_001_0	2																																																																																																																																																																																																																																																																																																		
H9185	002	0	1	20	08	H9185_002_0	2																																																																																																																																																																																																																																																																																																		
H9191	001	0	1	01	01	H9191_001_0	4	2				1	20	20	20	2				2		2	2	1		5000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9191	004	0	1	01	01	H9191_004_0	5	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9191	005	0	1	01	01	H9191_005_0	4	2				1	20	20	20	2				2		2	2	1		3000.00	3		2				2					2					2		2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	2	2	1	3		2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9207	002	0	1	01	01	H9207_002_0	16	2				2				1	40.00	40.00	40.00	2		1	2	1		2250.00	3		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	004	0	1	01	01	H9207_004_0	18	2				2				2				2		2	2	2					2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	2		5000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H9207	012	0	1	01	01	H9207_012_0	16	2				2				1	45.00	45.00	45.00	2		1	2	1		2250.00	3		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	013	0	1	01	01	H9207_013_0	19	2				2				1	15.00	15.00	15.00	2		1	2	1		3500.00	3		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	015	0	1	01	01	H9207_015_0	16	2				2				1	40.00	40.00	40.00	2		1	2	1		2250.00	3		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9207	016	0	1	01	01	H9207_016_0	16	2				2				2				2		2	2	2					2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	1	2		10000.00	3		2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																													
H9207	017	0	1	01	01	H9207_017_0	16	2				2				2				2		2	2	1		800.00	3		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2	2	1				2				2				2	2																														
H9207	018	0	1	01	01	H9207_018_0	22	2				2				1	40.00	40.00	40.00	2		1	2	1		5000.00	3		2				2					2					2		2	2	3	3		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	3	3		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2	2	1				2				2				2	2																														
H9219	004	0	1	04	01	H9219_004_0	4	2				2				1	0.00	0.00	0.00	2		1	2	1	2	750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9231	002	0	1	04	01	H9231_002_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	005	0	1	04	01	H9231_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	006	0	1	04	01	H9231_006_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	007	0	1	04	01	H9231_007_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	010	0	1	04	01	H9231_010_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	011	0	1	04	01	H9231_011_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	012	0	1	04	01	H9231_012_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	015	0	1	04	01	H9231_015_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9231	016	0	1	04	01	H9231_016_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9231	017	0	1	04	01	H9231_017_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9231	018	0	1	04	01	H9231_018_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9231	019	0	1	04	01	H9231_019_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9231	020	0	1	04	01	H9231_020_0	6	2				1	30	30	30	2				2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9252	001	0	1	20	08	H9252_001_0	2																																																																																																																																																																																																																																																																																																		
H9252	002	0	1	20	08	H9252_002_0	2																																																																																																																																																																																																																																																																																																		
H9266	001	0	1	20	08	H9266_001_0	2																																																																																																																																																																																																																																																																																																		
H9266	003	0	1	20	08	H9266_003_0	2																																																																																																																																																																																																																																																																																																		
H9306	002	0	1	01	01	H9306_002_0	9	2				2				1	40.00	40.00	40.00	2		2	2	1		5000.00	3		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9306	003	0	1	01	01	H9306_003_0	6	2				2				1	40.00	40.00	40.00	2		2	2	1		1500.00	3		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9306	004	0	1	01	01	H9306_004_0	6	2				1	20	20	20	2				2		2	2	1		2250.00	3		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	2				2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	2				2				1	2	2	2	1	6	in notes	2				2				1	2	2	2	1	6	in notes	2				2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	2				2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	2				2				1	2
H9306	007	0	1	01	01	H9306_007_0	7	2				2				1	40.00	40.00	40.00	2		2	2	1		1900.00	3		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	2				2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	2				2				1	2	2	2	1	6	in notes	2				2				1	2	2	2	1	6	in notes	2				2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	2				2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	2				2				1	2
H9306	008	1	1	01	01	H9306_008_1	7	2				2				1	40.00	40.00	40.00	2		2	2	1		3600.00	3		2				2					2					2		2	2	1	6	Oral Exams - Every 6 monthsComprehensive oral exam- every 36 monthsLimited Oral Evaluation - 3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	palliative treatment of dental pain - per visitdeep sedation/general anesthesia - first 15 minutesdeep sedation/general anesthesia-each 15 minute increment	1	20	20	20	2				1	2
H9306	008	2	1	01	01	H9306_008_2	7	2				2				1	40.00	40.00	40.00	2		2	2	1		3300.00	3		2				2					2					2		2	2	1	6	Oral Exams - Every 6 monthsComprehensive oral exam- every 36 monthsLimited Oral Evaluation - 3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	palliative treatment of dental pain - per visitdeep sedation/general anesthesia - first 15 minutesdeep sedation/general anesthesia-each 15 minute increment	1	20	20	20	2				1	2
H9306	009	1	1	01	01	H9306_009_1	7	2				2				1	40.00	40.00	40.00	2		2	2	1		3400.00	3		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9306	009	2	1	01	01	H9306_009_2	7	2				2				1	40.00	40.00	40.00	2		2	2	1		3200.00	3		2				2					2					2		2	2	1	6	Oral Exam Coverage: Oral Exams - Every 6 monthsComprehensive oral exam- once every 36 monthsLimited oral evaluations-3 per 12 months	2				2				2	2	2	2	1	6	in notes	2				2				2	2																2	2	1	4		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	Endodontics (1 per lifetime, per patient, per tooth)	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2	2	2	1	6	in notes	1	20	20	20	2				1	2																																														2	2	1	6	o Simple and surgical Extractions coveredo Coronectemy once per tooth per lifetime	1	20	20	20	2				1	2																2	2	1	6	o Palliative Treatment of dental pain - once per visito Deep sedation/general anesthesia - first 15 min    o Deep sedation/general anesthesia - each 15 min increment	1	20	20	20	2				1	2
H9314	001	0	1	01	01	H9314_001_0	2	2				1	20	20	20	2				2		1	2	1		2600.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																															2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H9317	001	0	1	20	08	H9317_001_0	2																																																																																																																																																																																																																																																																																																		
H9317	002	0	1	20	08	H9317_002_0	2																																																																																																																																																																																																																																																																																																		
H9323	001	0	1	20	08	H9323_001_0	2																																																																																																																																																																																																																																																																																																		
H9323	002	0	1	20	08	H9323_002_0	2																																																																																																																																																																																																																																																																																																		
H9326	001	0	1	04	01	H9326_001_0	8	2				2				1	55.00	55.00	55.00	2		2	2	1	2	600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9326	002	0	1	04	01	H9326_002_0	8	2				2				1	50.00	50.00	50.00	2		2	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9326	003	0	1	04	01	H9326_003_0	6	2				2				1	50.00	50.00	50.00	2		2	2	1	2	650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2															
H9326	801	0	1	04	01	H9326_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9360	001	0	1	20	08	H9360_001_0	3																																																																																																																																																																																																																																																																																																		
H9360	002	0	1	20	08	H9360_002_0	3																																																																																																																																																																																																																																																																																																		
H9364	001	0	1	02	01	H9364_001_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9364	002	0	1	02	01	H9364_002_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9364	003	0	1	02	01	H9364_003_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9364	004	0	1	02	01	H9364_004_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2						2					2																																																																																																																																									2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9387	001	0	1	04	01	H9387_001_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H9387	002	0	1	04	01	H9387_002_0	7	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	1500.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H9387	004	0	1	04	01	H9387_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2	2	3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H9411	001	0	1	20	08	H9411_001_0	2																																																																																																																																																																																																																																																																																																		
H9411	004	0	1	20	08	H9411_004_0	2																																																																																																																																																																																																																																																																																																		
H9412	803	0	1	04	01	H9412_803_0	1	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9431	014	0	1	04	01	H9431_014_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H9431	801	0	1	04	01	H9431_801_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9438	001	0	1	20	08	H9438_001_0	2																																																																																																																																																																																																																																																																																																		
H9438	002	0	1	20	08	H9438_002_0	2																																																																																																																																																																																																																																																																																																		
H9460	001	0	1	01	01	H9460_001_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H9460	003	0	1	01	01	H9460_003_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9468	001	0	1	20	08	H9468_001_0	2																																																																																																																																																																																																																																																																																																		
H9468	002	0	1	20	08	H9468_002_0	2																																																																																																																																																																																																																																																																																																		
H9485	001	0	1	04	01	H9485_001_0	5	2				2				1	50.00	50.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	1500.00	3		2					2		2	2	1	6	amalgam and resin fillings 1 per surface per tooth every calendar yearCrowns-1 per tooth per 5 calendar years.Re-cementing inlay/onlay, crown, post and core-1 per tooth per calendar year	2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	Every 5 years	2				2				2	2																															2	2	1	3		2				2				2	2	2	1				2				2				1	2																2	2	2	3		2				2				1	2
H9485	002	0	1	04	01	H9485_002_0	5	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	2500.00	3		2					2		2	2	1	6	amalgam and resin fillings 1 per surface per tooth every calendar yearCrowns-1 per tooth per 5 calendar years.Re-cementing inlay/onlay, crown, post and core-1 per tooth per calendar year	2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	every 5 years	2				2				2	2																															2	2	1	3		2				2				2	2	2	1				2				2				1	2																2	2	2	3		2				2				1	2
H9485	003	0	1	04	01	H9485_003_0	5	2				2				2				2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2	2	3000.00	3		2					2		2	2	1	6	amalgam and resin fillings 1 per surface per tooth every calendar yearCrowns-1 per tooth per 5 calendar years.Re-cementing inlay/onlay, crown, post and core-1 per tooth per calendar year.	2				2				1	2	2	2	1	3		2				2				1	2	2	2	2	3		2				2				1	2	2	2	1	6	every 5 years	2				2				2	2																															2	2	1	3		2				2				2	2	2	1				2				2				1	2																2	2	2	3		2				2				1	2
H9485	801	0	1	04	01	H9485_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9485	802	0	1	04	01	H9485_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9485	803	0	1	04	01	H9485_803_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	801	0	1	01	01	H9489_801_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	802	0	1	02	01	H9489_802_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	803	0	1	01	01	H9489_803_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	804	0	1	02	01	H9489_804_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	805	0	1	01	01	H9489_805_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	806	0	1	02	01	H9489_806_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	807	0	1	01	01	H9489_807_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9489	808	0	1	01	01	H9489_808_0	3	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9525	003	0	1	01	01	H9525_003_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	004	0	1	02	01	H9525_004_0	5	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H9525	006	0	1	02	01	H9525_006_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
H9525	011	0	1	02	01	H9525_011_0	5	2				2				1	0.00	0.00	0.00	2		1	2	1		2000.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	013	1	1	02	01	H9525_013_1	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	2	1	02	01	H9525_013_2	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	3	1	02	01	H9525_013_3	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	4	1	02	01	H9525_013_4	5	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	013	5	1	02	01	H9525_013_5	6	2				2				1	0.00	0.00	0.00	2		1	2	1		1500.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
H9525	018	0	1	01	01	H9525_018_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Endodontics-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	2				1	0.00	0.00	0.00	1	2
H9525	801	0	1	01	01	H9525_801_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	802	0	1	01	01	H9525_802_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	803	0	2	01	01	H9525_803_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	804	0	1	01	01	H9525_804_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	805	0	1	01	01	H9525_805_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	806	0	2	01	01	H9525_806_0	4	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	807	0	2	01	01	H9525_807_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	809	0	1	01	01	H9525_809_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	811	0	2	01	01	H9525_811_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	813	0	1	01	01	H9525_813_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	815	0	2	01	01	H9525_815_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9525	816	0	2	01	01	H9525_816_0	3	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9564	001	0	1	20	08	H9564_001_0	2																																																																																																																																																																																																																																																																																																		
H9564	002	0	1	20	08	H9564_002_0	2																																																																																																																																																																																																																																																																																																		
H9572	001	1	1	04	01	H9572_001_1	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	001	2	1	04	01	H9572_001_2	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	001	3	1	04	01	H9572_001_3	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	001	4	1	04	01	H9572_001_4	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	001	6	1	04	01	H9572_001_6	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	002	1	1	04	01	H9572_002_1	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	002	2	1	04	01	H9572_002_2	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	002	3	1	04	01	H9572_002_3	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	002	4	1	04	01	H9572_002_4	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	002	6	1	04	01	H9572_002_6	7	2				2				3		0.00	30.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays-bitewings or periapical	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	003	1	1	04	01	H9572_003_1	7	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	003	2	1	04	01	H9572_003_2	7	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	003	3	1	04	01	H9572_003_3	7	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	003	4	1	04	01	H9572_003_4	7	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	003	6	1	04	01	H9572_003_6	7	2				2				3		0.00	10.00	2		2	2	1	2	1500.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical. Full-mouth x-rays	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	004	1	1	04	01	H9572_004_1	9	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	004	2	1	04	01	H9572_004_2	8	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	004	4	1	04	01	H9572_004_4	9	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	004	6	1	04	01	H9572_004_6	8	2				2				3		0.00	45.00	2		2	2	1	2	950.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays - bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	007	1	1	04	01	H9572_007_1	8	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays once every 2 calendar years of either 1 set of up to 4 bitewings or up to 6 periapical.   Full mouth x-rays every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	007	2	1	04	01	H9572_007_2	8	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays once every 2 calendar years of either 1 set of up to 4 bitewings or up to 6 periapical.   Full mouth x-rays every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	007	3	1	04	01	H9572_007_3	8	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays once every 2 calendar years of either 1 set of up to 4 bitewings or up to 6 periapical.   Full mouth x-rays every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	007	4	1	04	01	H9572_007_4	8	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays once every 2 calendar years of either 1 set of up to 4 bitewings or up to 6 periapical.   Full mouth x-rays every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	007	6	1	04	01	H9572_007_6	8	2				2				3		0.00	50.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays once every 2 calendar years of either 1 set of up to 4 bitewings or up to 6 periapical.   Full mouth x-rays every 5 years.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings, Crowns, Crown Repairs	2				2				2	2	2	2	1	6	Root canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planing.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	008	0	1	04	01	H9572_008_0	7	2				2				3		0.00	55.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	Xray-bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H9572	009	0	1	04	01	H9572_009_0	7	2				2				3		0.00	45.00	2		2	2	1	2	1000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																1	1					2					2		4	2	1	6	Fillings - once per tooth/surface per 48 months.  Crowns - once per permanent tooth per 84 months.  Crown Repairs - three per tooth per calendar year.	2				2				2	2	2	2	1	6	Root Canals	2				2				2	2	4	2	1	6	Deep Cleaning - periodontal scaling and root planning.	2				2				2	2	3													2	2																3													2	2	3													2	2	2	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	2				2				2	2																3													2	2
H9572	010	0	1	04	01	H9572_010_0	7	2				2				3		0.00	50.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	X-rays -  bitewings or periapical.	2				2				2	2																2	2	2	3		2				2				2	2	2	2	1	3		2				2				2	2																																																																																																																																																																																		
H9572	801	0	1	04	01	H9572_801_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9572	802	0	1	04	01	H9572_802_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9572	806	0	1	04	01	H9572_806_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9572	807	0	1	04	01	H9572_807_0	2	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9589	003	0	1	04	01	H9589_003_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	1	4		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	2	2	3		2				2				2	2	1	2	2	2000.00	3		2					2		2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																2	2	2	3		2				2				2	2
H9590	001	0	1	01	01	H9590_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9592	001	0	1	20	08	H9592_001_0	2																																																																																																																																																																																																																																																																																																		
H9592	002	0	1	20	08	H9592_002_0	2																																																																																																																																																																																																																																																																																																		
H9615	021	0	1	04	01	H9615_021_0	16	2				2				1	50.00	50.00	50.00	2		2	2	1	2	750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9615	022	0	1	04	01	H9615_022_0	16	2				2				1	50.00	50.00	50.00	2		2	2	1	2	750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9615	023	0	1	04	01	H9615_023_0	16	2				2				1	50.00	50.00	50.00	2		2	2	1	2	750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9615	024	0	1	04	01	H9615_024_0	16	2				2				1	50.00	50.00	50.00	2		2	2	1	2	750.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9615	802	0	1	04	01	H9615_802_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9615	807	0	1	04	01	H9615_807_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9615	810	0	1	04	01	H9615_810_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9615	811	0	1	04	01	H9615_811_0	7	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9616	001	0	1	20	08	H9616_001_0	2																																																																																																																																																																																																																																																																																																		
H9616	002	0	1	20	08	H9616_002_0	2																																																																																																																																																																																																																																																																																																		
H9623	001	0	1	01	01	H9623_001_0	7	2				1	20	20	20	2				2		2	1																																																																																																																																																																																																																																																																																		
H9630	002	0	1	02	01	H9630_002_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H9630	008	0	1	02	01	H9630_008_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	40	40	40	2				1	2	2	2	1	6	once per tooth per lifetime	1	40	40	40	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	40	40	40	2				1	2																																																													2	2	1	6	every date of service to per lifetime	1	40	40	40	2				1	2																2	2	1	6	every date of service to 2 plan years	1	40	40	40	2				1	2
H9630	010	0	1	02	01	H9630_010_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H9630	011	0	1	02	01	H9630_011_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H9630	014	0	1	02	01	H9630_014_0	8	2				2				1	15.00	15.00	15.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	once per tooth per lifetime	1	20	20	20	2				1	2	2	2	1	6	every 6 months to 3 plan years	1	20	20	20	2				1	2	2	2	1	6	every date of service to 5 years	1	20	20	20	2				1	2																															2	2	1	6	every date of service to 7 plan years per tooth	1	20	20	20	2				1	2	2	2	1	6	every date of service to per lifetime	1	20	20	20	2				1	2																2	2	1	6	every date of service to 2 plan years	1	20	20	20	2				1	2
H9630	015	0	1	02	01	H9630_015_0	7	2				2				1	20.00	20.00	20.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H9649	001	0	1	20	08	H9649_001_0	2																																																																																																																																																																																																																																																																																																		
H9649	002	0	1	20	08	H9649_002_0	2																																																																																																																																																																																																																																																																																																		
H9678	002	0	1	04	01	H9678_002_0	7	2				2				2				2		1	2	1	2	1500.00	3		2				2					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	2	3		2				2				1	2	2	2	2	3		2				2				1	2	2	1				2				2				1	2	1	1					2					2		2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2	2	1				2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2	2	2	1	6	Limits vary by procedure.	2				2				1	2																2	2	1	6	Limits vary by procedure.	2				2				1	2
H9686	004	0	1	01	01	H9686_004_0	7	2				2				2				2		1	2	2					2				2					2					2		2	1				2				1	10.00	10.00	10.00	1	2	2	1				2				1	30.00	30.00	30.00	1	2																2	1				2				1	20.00	20.00	20.00	1	2	2	1				2				1	10.00	10.00	10.00	1	2																1	2		3500.00	3		2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	005	0	1	01	01	H9686_005_0	8	2				2				2				2		1	2	1		3700.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	006	0	1	01	01	H9686_006_0	7	2				2				2				2		1	2	1		3700.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	007	0	1	01	01	H9686_007_0	7	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	008	0	1	01	01	H9686_008_0	10	2				2				2				2		1	2	2					2				2					2					2		4	1				2				1	10.00	10.00	10.00	1	2	4	1				2				1	30.00	30.00	30.00	1	2																4	1				2				1	20.00	20.00	20.00	1	2	4	1				2				1	10.00	10.00	10.00	1	2																													3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																														
H9686	009	0	1	01	01	H9686_009_0	7	2				2				2				2		1	2	1		3000.00	3		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	1		2				2				1	2																2	2	1	4		2				2				1	2	2	2	1	4		2				2				1	2																1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																															2	1				2				2				1	2	2	1				2				2				1	2																														
H9686	801	0	1	01	01	H9686_801_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H9686	802	0	1	01	01	H9686_802_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H9686	803	0	1	01	01	H9686_803_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H9686	804	0	1	01	01	H9686_804_0	1	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H9690	001	0	1	01	01	H9690_001_0	4	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9699	007	0	1	01	01	H9699_007_0	5	2				2				1	35.00	35.00	35.00	2		2	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicities for covered services range from every year to every three years depending on the service.	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	3		1	20	20	20	2				2	2																2	2	2	6	Periodicities for covered services range from every year to every three years depending on the service.	1	20	20	20	2				2	2	2	2	2	6	Periodicities for covered services range from every year to every five years depending on the service.	1	20	20	20	2				2	2																																														2	1				1	20	20	20	2				2	2																2	2	2	3		1	20	20	20	2				2	2
H9700	001	0	1	04	01	H9700_001_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	002	0	1	04	01	H9700_002_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	003	0	1	04	01	H9700_003_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	004	0	1	04	01	H9700_004_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	005	0	1	04	01	H9700_005_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	006	0	1	04	01	H9700_006_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	007	0	1	04	01	H9700_007_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	008	0	1	04	01	H9700_008_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9700	009	0	1	04	01	H9700_009_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9706	001	0	1	01	01	H9706_001_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H9706	002	0	1	01	01	H9706_002_0	6	2				1	20	20	20	2				2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		4000.00	3		2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H9706	005	0	1	01	01	H9706_005_0	5	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
H9706	007	0	1	01	01	H9706_007_0	4	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		3000.00	3		2					2		2	1				1	0	0	0	2				2	2	2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2	2	1				1	20	20	20	2				2	2	2	1				1	20	20	20	2				2	2																2	1				1	20	20	20	2				2	2	2	1				3		0	20	2				2	2																2	1				1	0	0	0	2				2	2
H9706	008	0	1	01	01	H9706_008_0	6	2				2				1	35.00	35.00	35.00	2		2	2																																																																																																																																																																																																																																																																																		
H9706	009	0	1	01	01	H9706_009_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	3		2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		2	1				1	0	0	0	2				2	2	3													2	2	4	1				1	0	0	0	2				2	2	3													2	2	3													2	2																3													2	2	4	1				1	50	50	50	2				2	2																2	1				1	50	50	50	2				2	2
H9706	801	0	1	01	01	H9706_801_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9706	802	0	1	01	01	H9706_802_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9706	803	0	1	01	01	H9706_803_0	2	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9725	003	0	1	01	01	H9725_003_0	6	2				2				2				2		1	2	1		2000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	005	0	1	01	01	H9725_005_0	4	2				2				1	50.00	50.00	50.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	1	1	01	01	H9725_009_1	7	2				2				1	20.00	20.00	20.00	2		1	2	1		1850.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	2	1	01	01	H9725_009_2	6	2				2				1	10.00	10.00	10.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	3	1	01	01	H9725_009_3	6	2				2				1	15.00	15.00	15.00	2		1	2	1		1650.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	009	4	1	01	01	H9725_009_4	6	2				2				1	15.00	15.00	15.00	2		1	2	1		1600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	013	0	1	01	01	H9725_013_0	6	2				1	20	20	20	2				2		1	2	1		4000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	014	0	1	01	01	H9725_014_0	6	2				2				1	15.00	15.00	15.00	2		1	2	1		20000.00	3		2				2					2					2		2	2	4	3		2				2				2	2	2	2	1	6	Complete series x-rays (14 or more films or panoramic plus bitewings) and panoramic x-rays which are limited to once every three years. Four bitewing x-rays are covered every year.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				3		0.00	550.00	2	2	2	1				2				3		0.00	675.00	2	2	2	1				2				3		0.00	595.00	2	2	2	1				2				3		25.00	615.00	2	2																															2	1				2				3		50.00	525.00	2	2	2	1				2				2				2	2																2	1				2				3		0.00	285.00	2	2
H9725	015	1	1	01	01	H9725_015_1	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	015	2	1	01	01	H9725_015_2	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	015	3	1	01	01	H9725_015_3	6	2				2				1	45.00	45.00	45.00	2		1	2	1		600.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	015	4	1	01	01	H9725_015_4	6	2				2				1	45.00	45.00	45.00	2		1	2	1		500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	016	0	1	01	01	H9725_016_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1		1150.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	017	1	1	01	01	H9725_017_1	6	2				2				1	15.00	15.00	15.00	2		1	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	017	2	1	01	01	H9725_017_2	6	2				2				1	15.00	15.00	15.00	2		1	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	017	3	1	01	01	H9725_017_3	6	2				2				1	15.00	15.00	15.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	017	4	1	01	01	H9725_017_4	6	2				2				1	15.00	15.00	15.00	2		1	2	1		2300.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	018	0	1	02	01	H9725_018_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	019	0	1	01	01	H9725_019_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1		1150.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9725	801	0	1	01	01	H9725_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H9730	003	0	1	02	01	H9730_003_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9730	004	0	1	02	01	H9730_004_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		4000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H9730	007	0	1	02	01	H9730_007_0	8	2				2				1	40.00	40.00	40.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		1000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9730	009	0	1	02	01	H9730_009_0	8	2				2				1	35.00	35.00	35.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 5 plan years	2				1	0.00	0.00	0.00	1	2
H9730	010	0	1	02	01	H9730_010_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every date of service to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9730	011	0	1	02	01	H9730_011_0	8	2				2				1	25.00	25.00	25.00	2		1	2	2					2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	2	2	2	3		2				1	0.00	0.00	0.00	1	2	2	2	1	3		2				1	0.00	0.00	0.00	1	2	2	2	1	6	every date of service to 3 plan years	2				1	0.00	0.00	0.00	1	2	1	2		2000.00	3		2					2		2	2	1	6	every 1 to 7 plan years per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth per lifetime	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 3 plan years	2				1	0.00	0.00	0.00	1	2																																																													2	2	1	6	every date of service to per lifetime	2				1	0.00	0.00	0.00	1	2																2	2	1	6	every date of service to 2 plan years	2				1	0.00	0.00	0.00	1	2
H9771	001	0	1	01	01	H9771_001_0	2	2				1	20	20	20	2				2		1	2	1		2500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	2	6	See Notes	2				1	0.00	0.00	0.00	2	2																															2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2	2	2	1	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2
H9802	001	0	1	04	01	H9802_001_0	6	2				2				1	40.00	40.00	40.00	2		1	2	1	2	3000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9802	002	0	1	04	01	H9802_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9802	004	0	1	04	01	H9802_004_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	006	0	1	04	01	H9802_006_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	008	0	1	04	01	H9802_008_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9802	009	0	1	04	01	H9802_009_0	7	2				2				1	45.00	45.00	45.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9808	004	0	1	04	01	H9808_004_0	6	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2
H9808	005	0	1	04	01	H9808_005_0	6	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2
H9808	009	0	1	04	01	H9808_009_0	4	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2
H9808	010	0	1	04	01	H9808_010_0	6	2				2				1	35.00	35.00	35.00	2		2	2	2					2				2					1	111100	20.00	20.00	20.00	2		4	2	2	3		2								2	2	4	2	1	6	see notes	2								2	2	4	2	1	6	see notes	2								2	2	4	2	2	3		2								2	2																																																																																																																																																																																																	
H9808	807	0	1	04	01	H9808_807_0	1	2				2				1	25.00	25.00	25.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2
H9808	808	0	1	04	01	H9808_808_0	1	2				2				1	20.00	20.00	20.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2																															1	2	2	2000.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	2	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																2	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2
H9811	801	0	1	01	01	H9811_801_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
H9826	003	0	1	01	01	H9826_003_0	5	2				1	20	20	20	2				2		2	2	1		4500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9826	004	0	1	01	01	H9826_004_0	5	2				1	20	20	20	2				2		2	2	1		3500.00	3		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																																														2	1				2				2				2	2																2	1				2				2				2	2
H9827	001	0	1	01	01	H9827_001_0	7	2				2				1	30.00	30.00	30.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9827	003	0	1	01	01	H9827_003_0	4	2				2				1	25.00	25.00	25.00	2		2	2	1		1000.00	3		2				2					1	111111	0.00	0.00	0.00	2		2	2	2	3		2								2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2								2	2	4	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing and periapical, or 1 per consecutive 36 months for comprehensive series.	2								2	2	2	2	2	3		2								2	2	2	2	2	3		2								2	2	4	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		4	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2	4	2	1	6	Frequencies include one per tooth per lifetime, two per tooth per lifetime, or unlimited depending on service code.	1	70	70	70	2				2	2	4	2	1	6	Frequencies include unlimited, two per calendar year, two per consecutive 12 months, one per consecutive 36 months, or one per quadrant per consecutive 24 or 36 months depending on service code.	1	70	70	70	2				2	2	3													2	2																															3													2	2	4	2	1	6	Frequency includes unlimited, 1 per site per visit, consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 per consecutive 36 months, or 1 biopsy per site per visit depending on service code.	1	50	50	50	2				2	2																4	2	1	6	Frequency is unlimited, 1 per consecutive 6 months, or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9827	004	0	1	01	01	H9827_004_0	6	2				2				1	45.00	45.00	45.00	2		2	2	1		1000.00	3		2				2					2					2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	X-ray benefit is for bitewing x-rays two to eight per calendar year, vertical bitewing x-rays one per consecutive 36 months, or one full mouth x-ray every 36 consecutive months.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral tomosynthesis benefit is for two to eight x-rays per calendar year for bitewing, or 1 per consecutive 36 months for comprehensive series.	2				2				2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		2	2	1	6	Frequencies include unlimited, one per consecutive 6 months, one per consecutive 12 months, or one per consecutive 60 months depending on service code.	1	50	50	50	2				2	2																																																																																											2	2	1	6	1 tooth per lifetime.	1	50	50	50	2				2	2																2	2	1	6	Frequency is unlimited or 2 per calendar year depending on the service code.	2				1	0.00	0.00	0.00	2	2
H9827	801	0	1	01	01	H9827_801_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9827	802	0	1	01	01	H9827_802_0	1	2				3		20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9830	001	0	1	20	08	H9830_001_0	2																																																																																																																																																																																																																																																																																																		
H9830	002	0	1	20	08	H9830_002_0	2																																																																																																																																																																																																																																																																																																		
H9834	001	0	1	01	01	H9834_001_0	5	2				2				1	45.00	45.00	45.00	2		2	2	1		575.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	003	0	1	01	01	H9834_003_0	4	2				2				1	50.00	50.00	50.00	2		2	2	1		500.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	004	0	1	01	01	H9834_004_0	3	2				2				1	50.00	50.00	50.00	2		2	2	1		1000.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	006	0	1	01	01	H9834_006_0	4	2				2				1	60.00	60.00	60.00	2		2	2	1		400.00	3		2				2					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2																1	1					2					2		4	1				2				2				2	2	4	1				2				2				2	2	4	1				2				2				2	2	4	1				1	50	50	50	2				2	2																4	1				1	50	50	50	2				2	2	4	1				1	50	50	50	2				2	2	4	1				2				2				2	2																4	1				2				2				2	2
H9834	007	0	1	01	01	H9834_007_0	4	2				2				1	75.00	75.00	75.00	2		2	2	2					2				2					2					2		4	2	1	3		2				2				2	2	3													2	2	3													2	2	4	2	1	3		2				2				2	2	3													2	2																																																																																																																																																																																		
H9842	001	0	1	20	08	H9842_001_0	2																																																																																																																																																																																																																																																																																																		
H9842	002	0	1	20	08	H9842_002_0	2																																																																																																																																																																																																																																																																																																		
H9884	008	0	1	04	01	H9884_008_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9884	013	0	1	04	01	H9884_013_0	6	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9884	014	0	1	04	01	H9884_014_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9884	015	0	1	04	01	H9884_015_0	5	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	001	0	1	04	01	H9888_001_0	5	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	002	0	1	04	01	H9888_002_0	5	2				2				1	35.00	35.00	35.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	005	0	1	04	01	H9888_005_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	006	0	1	04	01	H9888_006_0	5	2				2				1	50.00	50.00	50.00	2		1	2	1	2	250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	007	0	1	04	01	H9888_007_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	008	0	1	04	01	H9888_008_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	009	0	1	04	01	H9888_009_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	010	0	1	04	01	H9888_010_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1	2	3500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9888	011	0	1	04	01	H9888_011_0	6	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	012	0	1	04	01	H9888_012_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	013	0	1	04	01	H9888_013_0	5	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	014	0	1	04	01	H9888_014_0	5	2				1	20	20	20	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9888	015	0	1	04	01	H9888_015_0	6	2				1	30	30	30	2				2		1	2	1	2	3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9904	001	0	1	04	01	H9904_001_0	7	2				2				1	30.00	30.00	30.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	1	2	2	1000.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																															2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2
H9904	002	0	1	04	01	H9904_002_0	9	2				2				1	45.00	45.00	45.00	2		2	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	1	2	2	1500.00	3		2					2		2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																															2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2																2	2	1	6	See notes for specific coverage and frequencies	2				2				2	2
H9907	002	1	1	04	01	H9907_002_1	10	2				2				1	65.00	65.00	65.00	2		1	2																																																																																																																																																																																																																																																																																		
H9907	002	2	1	04	01	H9907_002_2	10	2				2				1	65.00	65.00	65.00	2		1	2																																																																																																																																																																																																																																																																																		
H9907	002	3	1	04	01	H9907_002_3	10	2				2				1	65.00	65.00	65.00	2		1	2																																																																																																																																																																																																																																																																																		
H9907	801	0	1	04	01	H9907_801_0	4	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																		
H9907	802	0	1	04	01	H9907_802_0	4	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																		
H9907	803	0	1	04	01	H9907_803_0	4	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																		
H9907	804	0	1	04	01	H9907_804_0	4	2				2				1	45.00	45.00	45.00	2		1	2																																																																																																																																																																																																																																																																																		
H9909	001	0	1	01	01	H9909_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9916	001	0	1	02	01	H9916_001_0	8	2				1	20	20	20	2				2		1	2	2					2				2					2					2																																2	2	1	6	every day to 1 plan year	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every day to 1 year	2				1	0.00	0.00	0.00	1	2	1	2		3000.00	3		2					2		2	2	1	6	every 1 to 7 plan years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	once per tooth	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 to 36 months	2				1	0.00	0.00	0.00	1	2	2	2	1	6	every 6 months to 5 years	2				1	0.00	0.00	0.00	1	2																															2	2	1	6	every 7 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	per lifetime	2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
H9917	001	0	1	01	01	H9917_001_0	5	2				1	20	20	20	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	1					2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H9917	004	0	1	01	01	H9917_004_0	5	2				1	20	20	20	2				2		1	2	2					2				2					2					2		2	2	2	3		2				2				2	2	2	2	2	6	Refer to notes for periodicity details.	2				2				2	2	2	1				2				2				2	2	2	2	2	3		2				2				2	2	2	2	1	4		2				2				2	2																1	2		4000.00	3		2					2		2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	1				2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2	2	2	1	6	Refer to the Notes for periodicity details.	2				2				2	2																2	2	1	6	Refer to notes for periodicity details.	2				2				2	2
H9942	001	0	1	04	01	H9942_001_0	6	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
H9942	002	0	1	04	01	H9942_002_0	6	2				2				2				2		1	2																																																																																																																																																																																																																																																																																		
H9955	007	0	1	01	01	H9955_007_0	8	2				2				2				2		2	2	2					2				2					2					2		2	2	2	6	2 of periodic, limited, comprehensive, comprehensive periodontal evaluation per calendar year.1 Comprehensive or comprehensive periodontal evaluation per lifetime, per provider or location.	2				2				2	2	2	2	1	6	X-Rays: Periapicals up to 6/yr, Bitewings up to 4 per yr Panoramic or intraoral tomosynthesis-comprehensive series up to 1 every 5 yrs 1 of intraoral tomosynthesis periapical radiograph image per yr	2				2				2	2																2	2	2	3		2				2				2	2	2	2	2	3		2				2				2	2																1	2		6000.00	3		2					2		2	2	1	6	Up to 6 amalgam or resin fillings per yearUp to 2 inlay/onlay, crowns per calendar year.Crown repair-one per tooth per 5 years after 6 months of initial placement.	2				2				1	2	2	2	1	6	Endodontics covered one per tooth per year.	2				2				1	2	2	2	1	6	Periodontal root planing and scaling, full mouth debridement, and periodontal maintenance.	2				2				1	2	2	2	1	6	4 repairs including missing tooth, clasp, add teeth, replace teeth, rebases, relines or soft liner for complete/partial dentures per calendar yr. 1 denture set (full, partial, or immediate)/ 3 yrs	2				2				1	2																																														2	2	1	6	Extractions, removal of impacted teeth, incision and drainage of abscess.	2				2				1	2																2	2	1	6	Unlimited sedation based on Medical Necessity: Deep Sedation with Oral Surgery, Intravenous with Oral Surgery; palliative care-up to four every calendar year.	2				2				1	2
H9955	008	0	1	01	01	H9955_008_0	9	2				2				2				2		2	2																																																																																																																																																																																																																																																																																		
H9968	001	0	1	01	01	H9968_001_0	3	2				1	20	20	20	2				2		2	2																																																																																																																																																																																																																																																																																		
H9977	001	0	1	01	01	H9977_001_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9977	002	0	1	01	01	H9977_002_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9977	003	0	1	01	01	H9977_003_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9977	004	0	1	01	01	H9977_004_0	6	2				1	30	30	30	2				2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9977	005	0	1	01	01	H9977_005_0	6	2				2				1	25.00	25.00	25.00	2		1	2	1		2500.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				3		0	50	2				2	2	2	1				3		0	50	2				2	2	2	1				2				2				2	2	2	1				3		0	50	2				2	2																															2	1				3		0	50	2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9977	006	0	1	01	01	H9977_006_0	5	2				2				1	55.00	55.00	55.00	2		1	2	1		250.00	3		2				2					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2																															2	1				2				2				2	2	2	1				2				2				2	2																2	1				2				2				2	2
H9977	007	0	1	01	01	H9977_007_0	6	2				2				1	30.00	30.00	30.00	2		1	2	1		3000.00	3		2				2					2					2		2	2	2	6	Plan covers up to two oral exams per year.	2				2				2	2	2	2	1	6	Plan covers dental x-rays, and coverage frequency varies. For example, plan covers bitewing x-rays once per year and panoramic x-rays once every three years.	2				2				2	2																2	2	2	6	Plan covers up to two basic cleanings per year.	2				2				2	2	2	2	2	6	Plan covers up to two fluoride treatments per year.	2				2				2	2																1	1					2					2		2	2	1	6	Plan covers restorative services, such as fillings, once per surface every two years.	2				2				1	2	2	2	1	6	Plan covers endodontic services, such as root canal treatments, once per tooth per lifetime.	2				2				1	2	2	2	1	6	Plan covers periodontal services, such as deep cleaning, once every three years.	2				2				1	2	2	2	1	6	Plan covers dentures (once every five years)	2				2				1	2																															2	2	1	6	Plan covers fixed prosthodontics, such as the fake tooth (pontic) of the bridge, every five years.	2				2				1	2	2	2	1	6	Plan covers routine or surgical extractions once per tooth per lifetime.	2				2				1	2																2	2	1	6	Plan covers non-routine service such as pain treatment once per year.	2				2				1	2
H9986	001	0	1	01	01	H9986_001_0	7	2				1	20	20	20	2				2		2	2	1		912.50	5		2				2					2					2		2	2	1	4		2				2				2	2	2	2	1	3		2				2				2	2	2	1				2				2				2	2	2	2	1	4		2				2				2	2																2	1				2				2				2	2	1	1					2					2		2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2	2	1				2				2				2	2
H9986	002	0	1	02	01	H9986_002_0	8	2				1	20	20	20	2				2		2	2	1		862.50	5		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9986	004	1	1	02	01	H9986_004_1	10	2				1	20	20	20	2				2		2	2	1		1165.00	5		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9986	004	2	1	02	01	H9986_004_2	10	2				1	20	20	20	2				2		2	2	1		1095.00	5		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9986	004	3	1	02	01	H9986_004_3	10	2				1	20	20	20	2				2		2	2	1		1025.00	5		2				2					2					2		2	2	1	4		2				2				1	2	2	2	1	3		2				2				1	2	2	1				2				2				1	2	2	2	1	4		2				2				1	2																2	1				2				2				1	2	1	1					2					2		2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2	2	1				2				2				1	2																2	1				2				2				1	2
H9998	001	0	1	20	08	H9998_001_0	2																																																																																																																																																																																																																																																																																																		
H9998	002	0	1	20	08	H9998_002_0	2																																																																																																																																																																																																																																																																																																		
R0110	001	0	1	31	11	R0110_001_0	3	2				2				1	20.00	20.00	20.00	2		1	2	1	2	5000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
R0110	003	0	1	31	11	R0110_003_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
R0110	004	0	1	31	11	R0110_004_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	005	0	1	31	11	R0110_005_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R0110	006	0	1	31	11	R0110_006_0	4	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1750.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
R0110	007	0	1	31	11	R0110_007_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	008	0	1	31	11	R0110_008_0	3	2				2				1	45.00	45.00	45.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R0110	011	0	1	31	11	R0110_011_0	3	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	012	0	1	31	11	R0110_012_0	2	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R0110	013	0	1	31	11	R0110_013_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	014	0	1	31	11	R0110_014_0	3	2				2				1	60.00	60.00	60.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	015	0	1	31	11	R0110_015_0	2	2				2				1	35.00	35.00	35.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	016	0	1	31	11	R0110_016_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	017	0	1	31	11	R0110_017_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown-porc w/ high noble metal, crown-porc w/ noble metal, crown-porcelain/ ceramic 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2																																														2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	018	0	1	31	11	R0110_018_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1250.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core 1/tooth/lifetime, crown recement, crown-1/tooth/lifetime, filling unl/yr	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R0110	019	0	1	31	11	R0110_019_0	2	2				2				1	40.00	40.00	40.00	2		1	2	1	2	2000.00	3		2				2					2					2		2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2																2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																															2	1				2				1	0.00	0.00	0.00	1	2	2	1				2				1	0.00	0.00	0.00	1	2																2	1				2				1	0.00	0.00	0.00	1	2
R0110	020	0	1	31	11	R0110_020_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	2	3		2				1	25.00	25.00	25.00	1	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R0110	801	0	1	31	11	R0110_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	802	0	1	31	11	R0110_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	804	0	1	31	11	R0110_804_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	805	0	1	31	11	R0110_805_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	806	0	1	31	11	R0110_806_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	807	0	1	31	11	R0110_807_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	808	0	1	31	11	R0110_808_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	809	0	1	31	11	R0110_809_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	810	0	1	31	11	R0110_810_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	811	0	1	31	11	R0110_811_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	812	0	1	31	11	R0110_812_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	813	0	1	31	11	R0110_813_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	814	0	1	31	11	R0110_814_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	815	0	1	31	11	R0110_815_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	816	0	1	31	11	R0110_816_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0110	817	0	1	31	11	R0110_817_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R0759	001	0	1	31	11	R0759_001_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
R0759	002	0	1	31	11	R0759_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R0759	003	0	1	31	11	R0759_003_0	5	2				1	20	20	20	2				2		1	2	1	2	1500.00	3		2				2	000000				2	000000				2		2	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	2				1	0.00	0.00	0.00	1	2	2	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	2				1	0.00	0.00	0.00	1	2																2	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	2				1	0.00	0.00	0.00	1	2
R1532	001	0	1	31	11	R1532_001_0	4	2				2				1	40.00	40.00	40.00	2		1	2	1	2	4000.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown 1/tooth/5 yrs, filling 1/tooth/2 yrs	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
R1532	002	0	1	31	11	R1532_002_0	2	2				2				1	55.00	55.00	55.00	2		1	2	1	2	1500.00	3		2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	4	6	core buildup/prefab post/core 1/tooth/5 yrs, crown recement 1/2 years, crown-1/tooth/5 yrs, filling 1/tooth/2 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	6	scaling for mod inflammation 1/yr, scaling/root planing 1 per quadrant/3 yrs	2				1	0.00	0.00	0.00	1	2	2	2	11	6	comp dentures, part dentures 1/5 yrs, denture adj, reline, repair, tissue cond 2/yr, rebase 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement 1/yr, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	3		30	40	1	0.00	0.00	0.00	1	2	2	2	3	6	extractions 1/tooth/lifetime, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	6	6	emerg treatment for pain, necessary gen anesthesia with covered service 2/yr, necessary increm anesth with cov serv as needed with cov codes/yr, nec nitrous oxide/analgesia with cov serv 1 unit/visit, occlusal adj 1/lifetime	2				1	0.00	0.00	0.00	1	2
R1532	801	0	1	31	11	R1532_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R1532	802	0	1	31	11	R1532_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R2604	002	0	1	31	11	R2604_002_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R2604	005	0	1	31	11	R2604_005_0	5	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R3175	807	0	1	31	11	R3175_807_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
R3444	008	0	1	31	11	R3444_008_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R3444	009	0	1	31	11	R3444_009_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R3444	012	0	1	31	11	R3444_012_0	4	2				1	20	20	20	2				2		1	2	2					2				2	000000				2	000000				2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2	3													2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R4182	001	0	1	31	11	R4182_001_0	3	2				2				1	35.00	35.00	35.00	2		1	2	1	2	2500.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	2				1	0.00	0.00	0.00	1	2																																														2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R4182	003	0	1	31	11	R4182_003_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R4182	004	0	1	31	11	R4182_004_0	4	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R4182	801	0	1	31	11	R4182_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R4182	802	0	1	31	11	R4182_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R5342	805	0	1	31	11	R5342_805_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
R5361	001	0	1	31	11	R5361_001_0	3	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2	2	2	2	6	root canal, root canal retreat 1/tooth/lifetime	2				1	0.00	0.00	0.00	1	2	2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																															2	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	30	30	30	1	0.00	0.00	0.00	1	2	2	2	2	6	extractions unl/yr, oral surg 2/yr	2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R5361	002	0	1	31	11	R5361_002_0	3	2				1	20	20	20	2				2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R5361	801	0	1	31	11	R5361_801_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R5361	802	0	1	31	11	R5361_802_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R5826	005	0	1	31	11	R5826_005_0	2	2				2				1	45.00	45.00	45.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	2	3		2				1	25.00	25.00	25.00	1	2																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
R5826	018	0	1	31	11	R5826_018_0	2	2				2				1	30.00	30.00	30.00	2		1	2	1	2	1000.00	3		2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		2	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	2				1	0.00	0.00	0.00	1	2																2	2	2	1		2				1	0.00	0.00	0.00	1	2	2	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	30	30	30	1	0.00	0.00	0.00	1	2																																														2	1				2				1	0.00	0.00	0.00	1	2																2	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	2				1	0.00	0.00	0.00	1	2
R5826	074	0	1	31	11	R5826_074_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	3	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	2	2	1	1		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2																2	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2																																																																																																																																									2	1				2				1	0.00	0.00	0.00	1	2
R5826	805	0	1	31	11	R5826_805_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R5826	819	0	1	31	11	R5826_819_0	3	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R5941	013	0	1	31	11	R5941_013_0	6	2				2				1	0.00	0.00	0.00	2		1	2	1	2	1750.00	3		2				2					2					2		4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	6	2 series of bitewing films every year 1 panoramic radiograph or 1 intraoral complete series every 3 years	2				1	0.00	0.00	0.00	2	2	2	2	1	6	2 intraoral, bitewing radiographic images, image capture every year (shares frequency with bitewing x-rays)1 intraoral, comprehensive series of radiographic images, image capture every 3 years (shares frequency for the panoramic/complete series x-ray)	2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2	2	1				2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	2	1	6	Fillings-1 per surface per tooth every 2 yearsInlay / Onlay-1 per tooth every 5 yearsCrowns-1 per tooth every 5 yearsCore buildup, pin retention, post and core indirectly fabricated, and each additional prefabricated post-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Endodontics-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Root Planing / Scaling-1 per quad every 2 yearsSurgical Services / Grafting-1 per quad every 3 yearsMaintenance-2 per yearOsseous Surgery-1 per quad every 5 yearsFull Mouth Debridement-1 per quad every 2 yearsBone Replacement-1 per quad per lifetimeCrown Lengthening-1 per tooth per lifetime	1	25	25	25	2				1	2	4	2	1	6	Prosthodontics (Dentures)-1 complete or partial set every 5 yearsDenture Adjustments / Repair-1 per arch every yearDenture Reline and rebases-1 per arch every 2 yearsTissue conditioning-1 per arch every year	1	25	25	25	2				1	2																															2	2	1	6	Fixed partial dentures (bridges)-1 per tooth every 5 years	1	25	25	25	2				1	2	4	2	1	6	Simple & Surgical extractions-1 per tooth per lifetimeAlveoloplasty services-1 per quad per lifetimeBone replacement graft for ridge preservation-1 per site per lifetimeFrenuloplasty-1 every  5 yearsBiopsies-1 per site every 2 yearsExcision of hyperplastic tissue-1 per arch every 5 years	1	25	25	25	2				1	2																4	2	1	6	Deep sedation, intravenous conscious sedation, consultation-2 palliative (emergency) treatments, minor procedure every yearApplication of desensitizing medicament-1 every yearOcclusal guard-1 per arch every 3 yearsOcclusal adjustment-1 every 2 yearsTeledentistry-2 every year	1	25	25	25	2				1	2
R5941	014	0	1	31	11	R5941_014_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
R5941	016	0	1	31	11	R5941_016_0	6	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2					2					2		4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																4	2	1	3		2				1	0.00	0.00	0.00	2	2	3													2	2																																																																																																																																																																																		
R6694	006	0	1	31	11	R6694_006_0	3	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		2	2	4	3		2				1	0.00	0.00	0.00	2	2	2	2	3	6	See Notes	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																																	
R6801	008	0	1	31	11	R6801_008_0	4	2				2				1	0.00	0.00	0.00	2		1	2	2					2				2	000000				2	000000				2		2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Intraoral and panoramic: 1 every 3 years Single bitewing: 2 every year All other bitewing X-rays: 1 every year	2				1	0.00	0.00	0.00	2	2																2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	2	3		2				1	0.00	0.00	0.00	2	2	2	2	1	6	Nutritional counseling:  1 per floating 36 months  Interim caries arresting medicament application - per tooth: 2 per floating 12 months	2				1	0.00	0.00	0.00	2	2																																																																																																																																																																			
R6801	009	0	1	31	11	R6801_009_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
R6801	011	0	1	31	11	R6801_011_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
R6801	012	0	1	31	11	R6801_012_0	4	2				1	20	20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
R7220	001	0	1	31	11	R7220_001_0	3	2				2				1	60.00	60.00	60.00	2		1	2	1	2	1000.00	3		2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	1	1					2					2		4	1				2				1	0.00	0.00	0.00	1	2	3													2	2	4	2	2	1		2				1	0.00	0.00	0.00	1	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R7220	002	0	1	31	11	R7220_002_0	2	2				2				1	50.00	50.00	50.00	2		1	2	2					2				2					2					2		4	2	3	3		2				1	0.00	0.00	0.00	2	2	4	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	2				1	0.00	0.00	0.00	2	2	4	2	1	1		2				1	0.00	0.00	0.00	2	2	4	2	2	3		2				1	0.00	0.00	0.00	2	2																4	2	4	3		2				1	0.00	0.00	0.00	2	2	2						2					2		3													2	2	3													2	2	3													2	2	3													2	2																															3													2	2	3													2	2																4	1				2				1	0.00	0.00	0.00	1	2
R7220	801	0	1	31	11	R7220_801_0	1	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R7220	802	0	1	31	11	R7220_802_0	2	2				3		20	20	2				2		1	1																																																																																																																																																																																																																																																																																		
R7444	808	0	1	31	11	R7444_808_0	1	2				3		20	20	2				2		1	2																																																																																																																																																																																																																																																																																		
