pbp_a_hnumber	pbp_a_plan_identifier	segment_id	pbp_a_ben_cov	pbp_a_plan_type	orgtype	bid_id	version	pbp_d_opt_use_mand_16b_yn	pbp_d_opt_use_mand_16b1_yn	pbp_d_opt_use_mand_16b2_yn	pbp_d_opt_use_mand_16b3_yn	pbp_d_opt_use_mand_16b4_yn	pbp_d_opt_use_mand_16b5_yn	pbp_d_opt_use_mand_16b6_yn	pbp_d_opt_use_mand_16c_yn	pbp_d_opt_use_mand_16c1_yn	pbp_d_opt_use_mand_16c2_yn	pbp_d_opt_use_mand_16c3_yn	pbp_d_opt_use_mand_16c4_yn	pbp_d_opt_use_mand_16c5_yn	pbp_d_opt_use_mand_16c6_yn	pbp_d_opt_use_mand_16c7_yn	pbp_d_opt_use_mand_16c8_yn	pbp_d_opt_use_mand_16c9_yn	pbp_d_opt_use_mand_16c10_yn	pbp_b16b_maxplan_pv_yn	pbp_b16b_maxplan_pv_in_oon	pbp_b16b_maxplan_pv_amt	pbp_b16b_maxplan_pv_per	pbp_b16b_maxplan_pv_per_desc	pbp_b16b_maxenr_pv_yn	pbp_b16b_maxenr_pv_amt	pbp_b16b_maxenr_pv_per	pbp_b16b_maxenr_pv_per_desc	pbp_b16b_coins_ov_yn	pbp_b16b_coins_ov_svcs	pbp_b16b_coins_ov_pct	pbp_b16b_coins_ov_pct_min	pbp_b16b_coins_ov_pct_max	pbp_b16b_copay_ov_yn	pbp_b16b_copay_ov_svcs	pbp_b16b_copay_ov_amt	pbp_b16b_copay_ov_amt_min	pbp_b16b_copay_ov_amt_max	pbp_b16b_ded_pv_yn	pbp_b16b_ded_pv_amt	pbp_b16b_bendesc_oe_amo	pbp_b16b_bendesc_oe_lim	pbp_b16b_bendesc_oe_num	pbp_b16b_bendesc_oe_per	pbp_b16b_bendesc_oe_desc	pbp_b16b_coins_oe_yn	pbp_b16b_coins_oe_pct	pbp_b16b_coins_oe_pct_min	pbp_b16b_coins_oe_pct_max	pbp_b16b_copay_oe_yn	pbp_b16b_copay_oe_amt	pbp_b16b_copay_oe_amt_min	pbp_b16b_copay_oe_amt_max	pbp_b16b_auth_oe_yn	pbp_b16b_refer_oe_yn	pbp_b16b_bendesc_dx_amo	pbp_b16b_bendesc_dx_lim	pbp_b16b_bendesc_dx_num	pbp_b16b_bendesc_dx_per	pbp_b16b_bendesc_dx_desc	pbp_b16b_coins_dx_yn	pbp_b16b_coins_dx_pct	pbp_b16b_coins_dx_pct_min	pbp_b16b_coins_dx_pct_max	pbp_b16b_copay_dx_yn	pbp_b16b_copay_dx_amt	pbp_b16b_copay_dx_amt_min	pbp_b16b_copay_dx_amt_max	pbp_b16b_auth_dx_yn	pbp_b16b_refer_dx_yn	pbp_b16b_bendesc_ods_amo	pbp_b16b_bendesc_ods_lim	pbp_b16b_bendesc_ods_num	pbp_b16b_bendesc_ods_per	pbp_b16b_bendesc_ods_desc	pbp_b16b_coins_ods_yn	pbp_b16b_coins_ods_pct	pbp_b16b_coins_ods_pct_min	pbp_b16b_coins_ods_pct_max	pbp_b16b_copay_ods_yn	pbp_b16b_copay_ods_amt	pbp_b16b_copay_ods_amt_min	pbp_b16b_copay_ods_amt_max	pbp_b16b_auth_ods_yn	pbp_b16b_refer_ods_yn	pbp_b16b_bendesc_pc_amo	pbp_b16b_bendesc_pc_lim	pbp_b16b_bendesc_pc_num	pbp_b16b_bendesc_pc_per	pbp_b16b_bendesc_pc_desc	pbp_b16b_coins_pc_yn	pbp_b16b_coins_pc_pct	pbp_b16b_coins_pc_pct_min	pbp_b16b_coins_pc_pct_max	pbp_b16b_copay_pc_yn	pbp_b16b_copay_pc_amt	pbp_b16b_copay_pc_amt_min	pbp_b16b_copay_pc_amt_max	pbp_b16b_auth_pc_yn	pbp_b16b_refer_pc_yn	pbp_b16b_bendesc_ft_amo	pbp_b16b_bendesc_ft_lim	pbp_b16b_bendesc_ft_num	pbp_b16b_bendesc_ft_per	pbp_b16b_bendesc_ft_desc	pbp_b16b_coins_ft_yn	pbp_b16b_coins_ft_pct	pbp_b16b_coins_ft_pct_min	pbp_b16b_coins_ft_pct_max	pbp_b16b_copay_ft_yn	pbp_b16b_copay_ft_amt	pbp_b16b_copay_ft_amt_min	pbp_b16b_copay_ft_amt_max	pbp_b16b_auth_ft_yn	pbp_b16b_refer_ft_yn	pbp_b16b_bendesc_ops_amo	pbp_b16b_bendesc_ops_lim	pbp_b16b_bendesc_ops_num	pbp_b16b_bendesc_ops_per	pbp_b16b_bendesc_ops_desc	pbp_b16b_coins_ops_yn	pbp_b16b_coins_ops_pct	pbp_b16b_coins_ops_pct_min	pbp_b16b_coins_ops_pct_max	pbp_b16b_copay_ops_yn	pbp_b16b_copay_ops_amt	pbp_b16b_copay_ops_amt_min	pbp_b16b_copay_ops_amt_max	pbp_b16b_auth_ops_yn	pbp_b16b_refer_ops_yn	pbp_b16c_maxplan_cmp_yn	pbp_b16c_maxplan_cmp_type	pbp_b16c_maxplan_cmp_in_oon	pbp_b16c_maxplan_cmp_amt	pbp_b16c_maxplan_cmp_per	pbp_b16c_maxplan_cmp_per_desc	pbp_b16c_maxenr_cmp_yn	pbp_b16c_maxenr_cmp_type	pbp_b16c_maxenr_cmp_amt	pbp_b16c_maxenr_cmp_per	pbp_b16c_maxenr_cmp_per_desc	pbp_b16c_ded_cmp_yn	pbp_b16c_ded_cmp_amt	pbp_b16c_bendesc_rs_amo	pbp_b16c_bendesc_rs_lim	pbp_b16c_bendesc_rs_num	pbp_b16c_bendesc_rs_per	pbp_b16c_bendesc_rs_desc	pbp_b16c_coins_rs_yn	pbp_b16c_coins_rs_pct	pbp_b16c_coins_rs_pct_min	pbp_b16c_coins_rs_pct_max	pbp_b16c_copay_rs_yn	pbp_b16c_copay_rs_amt	pbp_b16c_copay_rs_amt_min	pbp_b16c_copay_rs_amt_max	pbp_b16c_auth_rs_yn	pbp_b16c_refer_rs_yn	pbp_b16c_bendesc_end_amo	pbp_b16c_bendesc_end_lim	pbp_b16c_bendesc_end_num	pbp_b16c_bendesc_end_per	pbp_b16c_bendesc_end_desc	pbp_b16c_coins_end_yn	pbp_b16c_coins_end_pct	pbp_b16c_coins_end_pct_min	pbp_b16c_coins_end_pct_max	pbp_b16c_copay_end_yn	pbp_b16c_copay_end_amt	pbp_b16c_copay_end_amt_min	pbp_b16c_copay_end_amt_max	pbp_b16c_auth_end_yn	pbp_b16c_refer_end_yn	pbp_b16c_bendesc_peri_amo	pbp_b16c_bendesc_peri_lim	pbp_b16c_bendesc_peri_num	pbp_b16c_bendesc_peri_per	pbp_b16c_bendesc_peri_desc	pbp_b16c_coins_peri_yn	pbp_b16c_coins_peri_pct	pbp_b16c_coins_peri_pct_min	pbp_b16c_coins_peri_pct_max	pbp_b16c_copay_peri_yn	pbp_b16c_copay_peri_amt	pbp_b16c_copay_peri_amt_min	pbp_b16c_copay_peri_amt_max	pbp_b16c_auth_peri_yn	pbp_b16c_refer_peri_yn	pbp_b16c_bendesc_prm_amo	pbp_b16c_bendesc_prm_lim	pbp_b16c_bendesc_prm_num	pbp_b16c_bendesc_prm_per	pbp_b16c_bendesc_prm_desc	pbp_b16c_coins_prm_yn	pbp_b16c_coins_prm_pct	pbp_b16c_coins_prm_pct_min	pbp_b16c_coins_prm_pct_max	pbp_b16c_copay_prm_yn	pbp_b16c_copay_prm_amt	pbp_b16c_copay_prm_amt_min	pbp_b16c_copay_prm_amt_max	pbp_b16c_auth_prm_yn	pbp_b16c_refer_prm_yn	pbp_b16c_bendesc_mxpr_amo	pbp_b16c_bendesc_mxpr_lim	pbp_b16c_bendesc_mxpr_num	pbp_b16c_bendesc_mxpr_per	pbp_b16c_bendesc_mxpr_desc	pbp_b16c_coins_mxpr_yn	pbp_b16c_coins_mxpr_pct	pbp_b16c_coins_mxpr_pct_min	pbp_b16c_coins_mxpr_pct_max	pbp_b16c_copay_mxpr_yn	pbp_b16c_copay_mxpr_amt	pbp_b16c_copay_mxpr_amt_min	pbp_b16c_copay_mxpr_amt_max	pbp_b16c_auth_mxpr_yn	pbp_b16c_refer_mxpr_yn	pbp_b16c_bendesc_impl_amo	pbp_b16c_bendesc_impl_lim	pbp_b16c_bendesc_impl_num	pbp_b16c_bendesc_impl_per	pbp_b16c_bendesc_impl_desc	pbp_b16c_coins_impl_yn	pbp_b16c_coins_impl_pct	pbp_b16c_coins_impl_pct_min	pbp_b16c_coins_impl_pct_max	pbp_b16c_copay_impl_yn	pbp_b16c_copay_impl_amt	pbp_b16c_copay_impl_amt_min	pbp_b16c_copay_impl_amt_max	pbp_b16c_auth_impl_yn	pbp_b16c_refer_impl_yn	pbp_b16c_bendesc_prf_amo	pbp_b16c_bendesc_prf_lim	pbp_b16c_bendesc_prf_num	pbp_b16c_bendesc_prf_per	pbp_b16c_bendesc_prf_desc	pbp_b16c_coins_prf_yn	pbp_b16c_coins_prf_pct	pbp_b16c_coins_prf_pct_min	pbp_b16c_coins_prf_pct_max	pbp_b16c_copay_prf_yn	pbp_b16c_copay_prf_amt	pbp_b16c_copay_prf_amt_min	pbp_b16c_copay_prf_amt_max	pbp_b16c_auth_prf_yn	pbp_b16c_refer_prf_yn	pbp_b16c_bendesc_omsg_amo	pbp_b16c_bendesc_omsg_lim	pbp_b16c_bendesc_omsg_num	pbp_b16c_bendesc_omsg_per	pbp_b16c_bendesc_omsg_desc	pbp_b16c_coins_omsg_yn	pbp_b16c_coins_omsg_pct	pbp_b16c_coins_omsg_pct_min	pbp_b16c_coins_omsg_pct_max	pbp_b16c_copay_omsg_yn	pbp_b16c_copay_omsg_amt	pbp_b16c_copay_omsg_amt_min	pbp_b16c_copay_omsg_amt_max	pbp_b16c_auth_omsg_yn	pbp_b16c_refer_omsg_yn	pbp_b16c_bendesc_orth_amo	pbp_b16c_bendesc_orth_lim	pbp_b16c_bendesc_orth_num	pbp_b16c_bendesc_orth_per	pbp_b16c_bendesc_orth_desc	pbp_b16c_coins_orth_yn	pbp_b16c_coins_orth_pct	pbp_b16c_coins_orth_pct_min	pbp_b16c_coins_orth_pct_max	pbp_b16c_copay_orth_yn	pbp_b16c_copay_orth_amt	pbp_b16c_copay_orth_amt_min	pbp_b16c_copay_orth_amt_max	pbp_b16c_auth_orth_yn	pbp_b16c_refer_orth_yn	pbp_b16c_bendesc_ags_amo	pbp_b16c_bendesc_ags_lim	pbp_b16c_bendesc_ags_num	pbp_b16c_bendesc_ags_per	pbp_b16c_bendesc_ags_desc	pbp_b16c_coins_ags_yn	pbp_b16c_coins_ags_pct	pbp_b16c_coins_ags_pct_min	pbp_b16c_coins_ags_pct_max	pbp_b16c_copay_ags_yn	pbp_b16c_copay_ags_amt	pbp_b16c_copay_ags_amt_min	pbp_b16c_copay_ags_amt_max	pbp_b16c_auth_ags_yn	pbp_b16c_refer_ags_yn	pbp_d_opt_identifier
H0028	017	0	1	01	01	H0028_017_0	3	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	021	0	1	01	01	H0028_021_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0028	053	3	1	01	01	H0028_053_3	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0107	003	0	1	04	01	H0107_003_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H0107	004	0	1	04	01	H0107_004_0	6								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H0107	005	0	1	04	01	H0107_005_0	6																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H0107	010	0	1	04	01	H0107_010_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H0107	011	0	1	04	01	H0107_011_0	5								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H0294	002	0	1	04	01	H0294_002_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	004	0	1	04	01	H0294_004_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	014	0	1	04	01	H0294_014_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	015	0	1	04	01	H0294_015_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	016	0	1	04	01	H0294_016_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	017	0	1	04	01	H0294_017_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	032	0	1	04	01	H0294_032_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0294	048	0	1	04	01	H0294_048_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0432	003	0	1	02	01	H0432_003_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0432	004	0	1	02	01	H0432_004_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0432	017	0	1	02	01	H0432_017_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0473	005	0	1	04	01	H0473_005_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H0504	015	0	1	01	01	H0504_015_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	015	0	1	01	01	H0504_015_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	017	0	1	01	01	H0504_017_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	017	0	1	01	01	H0504_017_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	021	0	1	01	01	H0504_021_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	021	0	1	01	01	H0504_021_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	026	0	1	01	01	H0504_026_0	6																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	026	0	1	01	01	H0504_026_0	6																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	028	0	1	01	01	H0504_028_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	028	0	1	01	01	H0504_028_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	038	0	1	01	01	H0504_038_0	5																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	038	0	1	01	01	H0504_038_0	5																			2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	039	0	1	01	01	H0504_039_0	5	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	001
H0504	040	0	1	01	01	H0504_040_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	040	0	1	01	01	H0504_040_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	041	0	1	01	01	H0504_041_0	6	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	041	0	1	01	01	H0504_041_0	6	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	043	0	1	01	01	H0504_043_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	043	0	1	01	01	H0504_043_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	047	0	1	01	01	H0504_047_0	5	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	047	0	1	01	01	H0504_047_0	5	2	2	2	2	2	2	2												2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0504	050	0	1	01	01	H0504_050_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		0.00	5.00	2	2	3	2	1	6	Periodicity range: No frequency limit for bitewing  single radiographic image, bitewings  two radiographic images covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.	2				2				2	2	3	1				2				3		0.00	10.00	2	2	3	2	1	4		2				1	5.00	5.00	5.00	2	2	3	1				2				2				2	2	3	2	1	6	Periodicity range: No frequency limit for nutritional counseling for control of dental disease, sealant  per tooth covered once every 36 months (exact tooth) from last date of service.	2				3		0.00	5.00	2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  one surface, primary or permanent, resin-based composite, one surface, posterior covered once every 12 months (exact tooth) from last date of service, labial veneer (resin laminate)  indirect covered once per plan year, every 5 years.	2				3		0.00	295.00	1	1	3	2	1	6	Periodicity range: No frequency range for apicoectomy  anterior, intraorifice barrier covered once every 12 months from last date of service (exact tooth surface), endodontic therapy  anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).	2				3		5.00	425.00	1	1	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	2				3		20.00	293.00	1	1	3	2	1	6	Periodicity range: Rebase complete maxillary denture covered once every 12 months from last date of service, complete denture  maxillary covered once per plan year every 5 years, immediate denture  maxillary covered once per lifetime.	2				3		10.00	310.00	1	1																															3	2	1	6	Periodicity range: No frequency limit for re-cement fixed or re-bond partial denture, pontic  cast high noble metal covered once per plan year (exact tooth) every 5 years.	2				3		12.00	275.00	1	1	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).	2				3		10.00	94.00	1	1																3	1				2				3		0.00	25.00	2	2	001
H0504	050	0	1	01	01	H0504_050_0	5	2	2	2	2	2	2	2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewings - 2 radiographic images covered once per plan year, panoramic radiographic image covered once every 24 months from last date of service.	3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for pulp vitality tests, diagnostic casts covered once every 24 months from last date of service.	3		0	30	2				2	2	3	2	1	4		3		0	20	2				2	2	3	2	1	3		3		0	20	2				2	2	3	2	1	6	Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 24 months (exact tooth) from last date of service.	3		0	20	2				2	2	2						2					2		3	2	1	6	Periodicity range: No frequency limit for amalgam  4 or more surfaces, primary or permanent, crown  resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Add clasp to existing partial denture  per tooth covered once every 6 months from last date of service, interim complete denture (maxillary) covered once every 5 years from last date of service.	1	50	50	50	2				2	2																3	2	1	6	Periodicity varies by the covered benefit. See Notes for more details.	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: Re-cement or re-bond fixed partial denture covered once every 6 months from last date of service, pontic  cast high noble metal covered once every 5 years from last date of service (exact tooth).	1	50	50	50	2				2	2	3	2	1	6	Periodicity range: No frequency limit for incisional biopsy of oral tissue - soft, removal of impacted tooth - soft tissue covered twice per lifetime (exact tooth).	1	50	50	50	2				2	2																3	2	1	6	Periodicity range: No frequency limit for palliative treatment of dental pain  per visit, fixed partial denture sectioning covered once every 6 months from last date of service, occlusal adjustment  limited covered once every 24 months from last date of service.	3		20	30	2				2	2	002
H0524	003	0	1	01	01	H0524_003_0	4	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	008	0	1	01	01	H0524_008_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	013	0	1	01	01	H0524_013_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	015	0	1	01	01	H0524_015_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	031	0	1	01	01	H0524_031_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	032	0	1	01	01	H0524_032_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	033	0	1	01	01	H0524_033_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	034	0	1	01	01	H0524_034_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	035	0	1	01	01	H0524_035_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	036	0	1	01	01	H0524_036_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	037	0	1	01	01	H0524_037_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	038	0	1	01	01	H0524_038_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	039	0	1	01	01	H0524_039_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	040	0	1	01	01	H0524_040_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	041	0	1	01	01	H0524_041_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	042	0	1	01	01	H0524_042_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	043	0	1	01	01	H0524_043_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	046	0	1	01	01	H0524_046_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	051	0	1	01	01	H0524_051_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	054	0	1	01	01	H0524_054_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	059	0	1	01	01	H0524_059_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	060	0	1	01	01	H0524_060_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	061	0	1	01	01	H0524_061_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	062	0	1	01	01	H0524_062_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	063	0	1	01	01	H0524_063_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	064	0	1	01	01	H0524_064_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	065	0	1	01	01	H0524_065_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	078	0	1	01	01	H0524_078_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	081	0	1	01	01	H0524_081_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	082	0	1	01	01	H0524_082_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0524	083	0	1	01	01	H0524_083_0	5	2		2					2			2							2	2					2				2					2					2																	3	2	1	6	Cone beam x-rays are covered once every calendar year. One interpretation of diagnostic image every calendar year. 3D printing of 3D scan, as needed.	2				3		0.00	105.00	1	1	3	2	1	2		2				1	0.00	0.00	0.00	1	1																															3	2	1	3		2				1	0.00	0.00	0.00	1	1	2						2					2		3	1				2				3		18.00	464.00	1	1	3	1				2				3		25.00	625.00	1	1	3	1				2				3		15.00	643.00	1	1	3	1				2				3		25.00	738.00	1	1																3	2	2	6	Re-cement or re-bond implant/abutment supported crown, one per arch every calendar year. One implant/abutment supported fixed denture for edentulous arch, every 5 years. The following are limited to no more than two (2) each per calendar year: Implants and Implant supported prosthetics.	2				3		41.00	2000.00	1	1	3	1				2				3		44.00	528.00	1	1	3	1				2				3		53.00	490.00	1	1																3	1				2				3		0.00	151.00	1	1	001
H0543	035	0	1	02	01	H0543_035_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	086	0	1	02	01	H0543_086_0	4	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	121	0	1	02	01	H0543_121_0	3	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	140	0	1	02	01	H0543_140_0	4	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	145	0	1	02	01	H0543_145_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	152	0	1	02	01	H0543_152_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	188	0	1	02	01	H0543_188_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	189	0	1	02	01	H0543_189_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	193	0	1	02	01	H0543_193_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	204	0	1	02	01	H0543_204_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	214	0	1	02	01	H0543_214_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	222	0	1	02	01	H0543_222_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	225	0	1	02	01	H0543_225_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	232	0	1	02	01	H0543_232_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	236	0	1	02	01	H0543_236_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	237	0	1	02	01	H0543_237_0	10	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	238	0	1	02	01	H0543_238_0	10	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	251	0	1	02	01	H0543_251_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0543	258	0	1	02	01	H0543_258_0	3	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0544	002	0	1	02	01	H0544_002_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	002	0	1	02	01	H0544_002_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	002	0	1	02	01	H0544_002_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	004	0	1	02	01	H0544_004_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	004	0	1	02	01	H0544_004_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	004	0	1	02	01	H0544_004_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	005	0	1	01	01	H0544_005_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	005	0	1	01	01	H0544_005_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	005	0	1	01	01	H0544_005_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	010	0	1	02	01	H0544_010_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	010	0	1	02	01	H0544_010_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	010	0	1	02	01	H0544_010_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	014	0	1	02	01	H0544_014_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	014	0	1	02	01	H0544_014_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	014	0	1	02	01	H0544_014_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	015	0	1	02	01	H0544_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	015	0	1	02	01	H0544_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	015	0	1	02	01	H0544_015_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	019	0	1	02	01	H0544_019_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	019	0	1	02	01	H0544_019_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	019	0	1	02	01	H0544_019_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	020	0	1	02	01	H0544_020_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	020	0	1	02	01	H0544_020_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	020	0	1	02	01	H0544_020_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	056	0	1	02	01	H0544_056_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	056	0	1	02	01	H0544_056_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	056	0	1	02	01	H0544_056_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	058	0	1	02	01	H0544_058_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	058	0	1	02	01	H0544_058_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	058	0	1	02	01	H0544_058_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	061	0	1	02	01	H0544_061_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	061	0	1	02	01	H0544_061_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	061	0	1	02	01	H0544_061_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	062	0	1	02	01	H0544_062_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	062	0	1	02	01	H0544_062_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	062	0	1	02	01	H0544_062_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	063	0	1	02	01	H0544_063_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	063	0	1	02	01	H0544_063_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	063	0	1	02	01	H0544_063_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	064	0	1	02	01	H0544_064_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	064	0	1	02	01	H0544_064_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	064	0	1	02	01	H0544_064_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	065	0	1	02	01	H0544_065_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	065	0	1	02	01	H0544_065_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	065	0	1	02	01	H0544_065_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	066	0	1	02	01	H0544_066_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	066	0	1	02	01	H0544_066_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	066	0	1	02	01	H0544_066_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	069	0	1	02	01	H0544_069_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	069	0	1	02	01	H0544_069_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	069	0	1	02	01	H0544_069_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	095	0	1	02	01	H0544_095_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	095	0	1	02	01	H0544_095_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	095	0	1	02	01	H0544_095_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	096	0	1	02	01	H0544_096_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	096	0	1	02	01	H0544_096_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	096	0	1	02	01	H0544_096_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	098	0	1	02	01	H0544_098_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	098	0	1	02	01	H0544_098_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	098	0	1	02	01	H0544_098_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0544	108	0	1	02	01	H0544_108_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0544	108	0	1	02	01	H0544_108_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H0544	108	0	1	02	01	H0544_108_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H0571	001	0	1	01	01	H0571_001_0	9	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	007	0	1	01	01	H0571_007_0	10	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	010	0	1	01	01	H0571_010_0	9	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0571	011	0	1	01	01	H0571_011_0	10	2	1	1	2	2			2			2							2	2					2				2					2					2																																3	1				2				3		0.00	70.00	2	2	3	2	1	4		2				2				2	2																															2						2					2		3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	380.00	2	2	3	1				2				3		0.00	275.00	2	2	3	2	1	3		2				3		12.00	415.00	2	2																															3	2	1	3		2				3		20.00	380.00	2	2	3	1				2				3		0.00	130.00	2	2	3	2	1	3		2				3		0.00	2415.00	2	2	3	2	1	3		2				3		0.00	125.00	2	2	001
H0609	012	0	1	02	01	H0609_012_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	026	0	1	02	01	H0609_026_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	036	1	1	02	01	H0609_036_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	036	2	1	02	01	H0609_036_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	040	0	1	02	01	H0609_040_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	042	0	1	02	01	H0609_042_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	051	0	1	02	01	H0609_051_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	054	0	1	02	01	H0609_054_0	4	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	055	0	1	02	01	H0609_055_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	058	0	1	02	01	H0609_058_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	059	0	1	02	01	H0609_059_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	060	0	1	02	01	H0609_060_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	062	0	1	02	01	H0609_062_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	066	0	1	02	01	H0609_066_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	067	0	1	02	01	H0609_067_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	068	0	1	02	01	H0609_068_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	072	0	1	02	01	H0609_072_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0609	077	0	1	02	01	H0609_077_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0630	013	0	1	01	01	H0630_013_0	5								2	2	2	2							2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	015	0	1	02	01	H0630_015_0	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	016	0	1	02	01	H0630_016_0	6								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	017	0	1	01	01	H0630_017_0	5								2	2	2	2							2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	020	0	1	01	01	H0630_020_0	5								2	2	2	2							2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	021	0	1	02	01	H0630_021_0	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	023	0	1	02	01	H0630_023_0	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0630	025	0	1	02	01	H0630_025_0	5								2	2	2	2	2	2		2	2		2																																																																																																																1	2		1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H0755	030	0	1	02	01	H0755_030_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	031	0	1	02	01	H0755_031_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	032	0	1	02	01	H0755_032_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	033	0	1	02	01	H0755_033_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	038	0	1	02	01	H0755_038_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	044	0	1	02	01	H0755_044_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H0755	045	0	1	02	01	H0755_045_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1036	318	0	1	02	01	H1036_318_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	319	0	1	01	01	H1036_319_0	2	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	323	0	1	01	01	H1036_323_0	3	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1036	334	0	1	01	01	H1036_334_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H1170	002	0	1	01	01	H1170_002_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	009	0	1	01	01	H1170_009_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	012	0	1	01	01	H1170_012_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	013	0	1	02	01	H1170_013_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	014	0	1	01	01	H1170_014_0	5	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	016	0	1	01	01	H1170_016_0	6	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1170	017	0	1	01	01	H1170_017_0	5	2		2					2	2	2	2	2				2		2	2					2														2																	3	2	1	3		2				3		11.00	105.00	2	2																																																													2						2					2		3	2	1	6	Pin retention, recent or rebonding, Prefabricated porcelain/ceramic crown  permanent tooth: 1 per tooth/2 years; protective restoration: 1 per tooth /lifetime; fillings: 2/1 year	2				3		7.00	45.00	1	1	3	2	1	6	Therapeutic pulpotomy excl final restoration, Apicoectomy, retrograde filling per root, root amputation per root: 1 per tooth/lifetime; root canal procedures: 2/year; root canal per tooth: 1/lifetime	2				3		9.00	250.00	1	1	3	2	1	6	Gingivectomy or gingivoplasty, Gingival flap procedure, Osseous surgery: 1 per quadrant/3 years; Clinical crown lengthening: 1 per tooth/lifetime; Guided tissue regeneration: 1 per tooth/3 years; Full mouth debridement: 1/2 years	2				3		9.00	257.00	1	1	3	2	1	6	denture: 1/5 years for complete or partial maxillary or mandibular; rebasing: 1/2 years; Repair broken denture base: 1/year; Reline denture: 2/year	2				3		19.00	171.00	1	1																3	2	1	6	Re-cement or re-bond implant/abutment: 1/year; Implant/abutment supported fixed denture: 1/ 5 years; Implant supported crown: 1/ year; Abutment supported crown or retainer: 2 / year	2				3		41.00	2000.00	1	1																3	2	1	6	extraction: 3/year; extraction: 1/tooth/lifetime; Alveoloplasty: 1/quadrant/lifetime; Tooth re-implantation and/or stabilization: 1/tooth/lifetime; Vestibuloplasty: 1/arch/lifetime	2				3		21.00	196.00	1	1																3	2	1	6	External bleaching for home application, per arch: 1 tray and gel for 2 weeks; Occlusal adjustment: 1/5 years; Non-intravenous conscious sedation: 3/year; max of 60 min of General anesthesia or Intravenous moderate sedation allowed per date of service	2				3		9.00	60.00	1	1	001
H1181	001	0		07	02	H1181_001_0	3																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1225	001	0	1	01	01	H1225_001_0	9																																																																																																																																		1	2		1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H1230	001	0	1	01	01	H1230_001_0	3								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	003	0	1	01	01	H1230_003_0	3								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	013	0	1	01	01	H1230_013_0	3								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1230	014	0	1	01	01	H1230_014_0	3								2	2		2							2	2					2				2					2					2																																																														3	2	1	3		1	30	30	30	2				2	2	3	2	2	6	Two applications per tooth per 12 month period, limited to six teeth per visit.	1	30	30	30	2				2	2	1	2		1000.00	3		2					2		3	2	1	6	Fillings once every 24 months and crowns once every seven years.	3		30	50	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	30	30	30	2				2	2																3	1				3		30	50	2				2	2	001
H1278	003	0	1	04	01	H1278_003_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	005	0	1	04	01	H1278_005_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	010	0	1	04	01	H1278_010_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	013	0	1	04	01	H1278_013_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	014	0	1	04	01	H1278_014_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	015	0	1	04	01	H1278_015_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	016	0	1	04	01	H1278_016_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	020	0	1	04	01	H1278_020_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	021	0	1	04	01	H1278_021_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	024	0	1	04	01	H1278_024_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	025	0	1	04	01	H1278_025_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	026	0	1	04	01	H1278_026_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	027	0	1	04	01	H1278_027_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	028	0	1	04	01	H1278_028_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	029	0	1	04	01	H1278_029_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	030	0	1	04	01	H1278_030_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1278	032	0	1	04	01	H1278_032_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1350	032	0	1	01	01	H1350_032_0	7																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	033	0	1	01	01	H1350_033_0	7																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	034	0	1	01	01	H1350_034_0	7																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	035	0	1	01	01	H1350_035_0	7																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	036	0	1	01	01	H1350_036_0	7																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1350	037	0	1	01	01	H1350_037_0	8																																																																																																																																		2						2					1	50.00	3	2	1	6	Same tooth surface restoration is covered once in a two year period.	1	20	20	20	2				1	2	3	2	1	6	Root canals not to exceed one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	4	6	Root scaling and planing 1 procedure per quadrant every 2 years not to exceed 4 quadrants, full mouth debridement 1 procedure every 3 years, periodontal maintenance not to exceed 4 visits per year.	1	20	20	20	2				1	2	3	2	1	6	Bridge and bridge repair not to exceed one per tooth every seven years.	1	50	50	50	2				1	2																															3	2	1	6	Bridge, bridge repair, and crowns not to exceed one per tooth every seven years.	1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2																															001
H1423	001	0	1	02	01	H1423_001_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	001	0	1	02	01	H1423_001_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	001	0	1	02	01	H1423_001_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	002	0	1	02	01	H1423_002_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	002	0	1	02	01	H1423_002_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	002	0	1	02	01	H1423_002_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	004	0	1	02	01	H1423_004_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	004	0	1	02	01	H1423_004_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	004	0	1	02	01	H1423_004_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	005	0	1	01	01	H1423_005_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	005	0	1	01	01	H1423_005_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	005	0	1	01	01	H1423_005_0	7																			2					1	500.00	3		2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	007	0	1	01	01	H1423_007_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	007	0	1	01	01	H1423_007_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	007	0	1	01	01	H1423_007_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	008	0	1	01	01	H1423_008_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	008	0	1	01	01	H1423_008_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	008	0	1	01	01	H1423_008_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1423	009	0	1	02	01	H1423_009_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1423	009	0	1	02	01	H1423_009_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1423	009	0	1	02	01	H1423_009_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1607	012	0	1	04	01	H1607_012_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1607	012	0	1	04	01	H1607_012_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1607	012	0	1	04	01	H1607_012_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1607	015	0	1	04	01	H1607_015_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H1607	015	0	1	04	01	H1607_015_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H1607	015	0	1	04	01	H1607_015_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H1666	003	0	1	04	01	H1666_003_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1666	006	0	1	04	01	H1666_006_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1666	008	0	1	04	01	H1666_008_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1666	012	0	1	04	01	H1666_012_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1666	014	0	1	04	01	H1666_014_0	6																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1666	019	0	1	04	01	H1666_019_0	7								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H1666	021	0	1	04	01	H1666_021_0	6																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1666	023	0	1	04	01	H1666_023_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H1846	005	0	1	04	01	H1846_005_0	7	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	005	0	1	04	01	H1846_005_0	7	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1846	006	0	1	04	01	H1846_006_0	6	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	006	0	1	04	01	H1846_006_0	6	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1846	007	0	1	04	01	H1846_007_0	6	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H1846	007	0	1	04	01	H1846_007_0	6	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H1889	013	0	1	04	01	H1889_013_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	015	0	1	04	01	H1889_015_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	016	0	1	04	01	H1889_016_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	017	0	1	04	01	H1889_017_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	020	0	1	04	01	H1889_020_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1889	025	0	1	04	01	H1889_025_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1961	020	0	1	02	01	H1961_020_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1961	023	0	1	02	01	H1961_023_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H1961	025	0	1	02	01	H1961_025_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	010	0	1	04	01	H2001_010_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	019	0	1	04	01	H2001_019_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	023	0	1	04	01	H2001_023_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	055	0	1	04	01	H2001_055_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	070	0	1	04	01	H2001_070_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	083	1	1	04	01	H2001_083_1	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	083	2	1	04	01	H2001_083_2	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	087	0	1	04	01	H2001_087_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	090	0	1	04	01	H2001_090_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	094	0	1	04	01	H2001_094_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	095	0	1	04	01	H2001_095_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	097	0	1	04	01	H2001_097_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	098	0	1	04	01	H2001_098_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	103	0	1	04	01	H2001_103_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	104	0	1	04	01	H2001_104_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	108	0	1	04	01	H2001_108_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	110	0	1	04	01	H2001_110_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	116	0	1	04	01	H2001_116_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	117	0	1	04	01	H2001_117_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	119	0	1	04	01	H2001_119_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	123	0	1	04	01	H2001_123_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	127	0	1	04	01	H2001_127_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	128	0	1	04	01	H2001_128_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	131	0	1	04	01	H2001_131_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	132	0	1	04	01	H2001_132_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	133	0	1	04	01	H2001_133_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	135	0	1	04	01	H2001_135_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2001	137	0	1	04	01	H2001_137_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2172	001	0	1	02	01	H2172_001_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	001	0	1	02	01	H2172_001_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	002	0	1	02	01	H2172_002_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	002	0	1	02	01	H2172_002_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	005	0	1	01	01	H2172_005_0	3								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	005	0	1	01	01	H2172_005_0	3								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	008	0	1	02	01	H2172_008_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	008	0	1	02	01	H2172_008_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	009	0	1	02	01	H2172_009_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	009	0	1	02	01	H2172_009_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	010	0	1	02	01	H2172_010_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	010	0	1	02	01	H2172_010_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	013	0	1	02	01	H2172_013_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	013	0	1	02	01	H2172_013_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	014	0	1	02	01	H2172_014_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	014	0	1	02	01	H2172_014_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	020	0	1	02	01	H2172_020_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	020	0	1	02	01	H2172_020_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	021	0	1	02	01	H2172_021_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	021	0	1	02	01	H2172_021_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	022	0	1	02	01	H2172_022_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	022	0	1	02	01	H2172_022_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	023	0	1	02	01	H2172_023_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	023	0	1	02	01	H2172_023_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	024	0	1	02	01	H2172_024_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	024	0	1	02	01	H2172_024_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	025	0	1	01	01	H2172_025_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	025	0	1	01	01	H2172_025_0	5								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	026	0	1	01	01	H2172_026_0	5																																																																																																																																		1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	026	0	1	01	01	H2172_026_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2172	027	0	1	02	01	H2172_027_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		500.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	001
H2172	027	0	1	02	01	H2172_027_0	4								2	2	2	2	2			2	2		2																																																																																																																1	2		1000.00	3		2					2		3	2	1	6	Fillings limited to one every two years per surface per tooth. Inlays, onlays, and crowns limited to one per tooth per five years.	1	50	50	50	2				1	2	3	2	1	6	Endodontic therapy and retreatment limited to one per tooth per lifetime.	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing limited to one per quadrant per two years. Full mouth debridement limited to one per three years. Periodontal maintenance limited to two per year.	1	50	50	50	2				1	2	3	2	1	6	Dentures limited to one per five years & adjustments to two per denture per year. Repairs & relines limited to one per denture per year.	1	50	50	50	2				1	2																															3	2	1	6	Pontics and retainer crowns limited to one per tooth per five years. Re-cement & re-bond fixed partial denture limited to one per site per year.	1	50	50	50	2				1	2	3	2	1	6	Extractions are limited to one per tooth.	1	50	50	50	2				1	2																3	2	1	6	Palliative treatment of dental pain is limited to one per visit per year.	1	50	50	50	2				1	2	002
H2256	001	1	1	01	01	H2256_001_1	9																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	001	2	1	01	01	H2256_001_2	8																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	001	6	1	01	01	H2256_001_6	9																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	1	1	01	01	H2256_015_1	9																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	2	1	01	01	H2256_015_2	9																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	015	6	1	01	01	H2256_015_6	9																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	016	1	1	01	01	H2256_016_1	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	016	2	1	01	01	H2256_016_2	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	1	1	01	01	H2256_018_1	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	7	1	01	01	H2256_018_7	8	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	018	8	1	01	01	H2256_018_8	8	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	019	1	1	01	01	H2256_019_1	7	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	019	7	1	01	01	H2256_019_7	7	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	1	1	01	01	H2256_026_1	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	2	1	01	01	H2256_026_2	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	026	3	1	01	01	H2256_026_3	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	033	0	1	01	01	H2256_033_0	9																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	034	0	1	01	01	H2256_034_0	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	036	0	1	01	01	H2256_036_0	9	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	039	0	1	01	01	H2256_039_0	7																			2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																3	2	2	3		2				2				2	2																															2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	040	0	1	01	01	H2256_040_0	7	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	041	0	1	01	01	H2256_041_0	7	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2256	042	0	1	01	01	H2256_042_0	7	2	2	2		1			2	2		2					2		2	2					2				2					2					2		3	2	4	6	Covers up to 4 visits in a calendar year: 2 periodic oral evaluations per year; 1 emergency oral evaluation, problem focused exam, every 12 months; and 1 comprehensive oral evaluation every 36 months.	3		0	20	2				2	2	3	2	5	6	Covers up to 5 X-ray images per year: 2 intra-oral bitewings every year; 1 intra-oral panoramic every 60 months; 1 intra-oral full mouth series every 60 months; & single tooth as needed.	3		0	20	2				2	2																																																													2						2					2		3	2	6	6	Covers 1 amalgam/composite filling per tooth per 24 mos; 1 protective restoration per tooth; 1 inlay, initial crown/onlay, buildup, post&core per tooth per 84 mos; 1 recement of crown/onlay per 12 mos	3		20	50	2				2	2	3	2	3	6	Coverage up to 3 visits every year: 1 root canal per tooth per lifetime; 1 retreatment per tooth per lifetime, at least 24 months after initial treatment; and 1 apicoectomy per tooth per lifetime.	1	50	50	50	2				2	2	3	2	6	6	Covers 1 perio cleaning per 6 mos or 1 scaling per 24 mos; 1 scaling&root planing per quadrant per 24 mos & 1 full mouth debridement, 1 perio surg & 1 bone graft/guided tissue regeneration a lifetime.	3		20	50	2				2	2	3	2	6	6	Covers up to 6 visits a year: 1 temp partial denture, 1 complete/partial per arch, 1 tissue conditioning, 1 addition of teeth to existing denture & 1 rebase/reline per 84 mos; 1 repair per 24 mos.	1	50	50	50	2				2	2																															3	2	2	6	Covers 2 visits per year: 1 fixed bridge per 84 months and 1 bridge repair per 24 months.	1	50	50	50	2				2	2	3	2	2	6	Covers 1 extraction, simple or surgical, per tooth.	3		20	50	2				2	2																3	2	2	6	Covers up to 2 visits every year: 1 local anesthesia & inhalation of nitrous oxide/analgesia with covered surgery and 1 minor treatment for pain relief when only exam & X-rays performed on same date.	3		20	50	2				2	2	001
H2320	022	1	1	02	01	H2320_022_1	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	2	1	02	01	H2320_022_2	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	3	1	02	01	H2320_022_3	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	4	1	02	01	H2320_022_4	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	022	5	1	02	01	H2320_022_5	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	1	1	02	01	H2320_028_1	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	2	1	02	01	H2320_028_2	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	3	1	02	01	H2320_028_3	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	4	1	02	01	H2320_028_4	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	028	5	1	02	01	H2320_028_5	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	1	1	02	01	H2320_029_1	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	2	1	02	01	H2320_029_2	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	3	1	02	01	H2320_029_3	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	4	1	02	01	H2320_029_4	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	029	5	1	02	01	H2320_029_5	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	031	0	1	02	01	H2320_031_0	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	032	1	1	02	01	H2320_032_1	5	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	032	2	1	02	01	H2320_032_2	5	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2320	032	5	1	02	01	H2320_032_5	5	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2		2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H2322	008	0	1	04	01	H2322_008_0	7								2			2								1	2	2000.00	3		2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2322	011	0	1	04	01	H2322_011_0	7								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2322	016	0	1	04	01	H2322_016_0	6								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	015	0	1	01	01	H2354_015_0	6								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	018	0	1	01	01	H2354_018_0	7								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	019	0	1	01	01	H2354_019_0	5								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	021	0	1	02	01	H2354_021_0	7								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2354	028	0	1	01	01	H2354_028_0	6								2			2								2					2														2																																3	1				2				2				2	2																																														2						2					2																																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														001
H2406	039	0	1	04	01	H2406_039_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	040	0	1	04	01	H2406_040_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	041	0	1	04	01	H2406_041_0	3	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	044	0	1	04	01	H2406_044_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	048	0	1	04	01	H2406_048_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	056	0	1	04	01	H2406_056_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	059	0	1	04	01	H2406_059_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	062	0	1	04	01	H2406_062_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	065	0	1	04	01	H2406_065_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	066	0	1	04	01	H2406_066_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	067	0	1	04	01	H2406_067_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	068	0	1	04	01	H2406_068_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	069	0	1	04	01	H2406_069_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	070	0	1	04	01	H2406_070_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	071	0	1	04	01	H2406_071_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	072	0	1	04	01	H2406_072_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	075	0	1	04	01	H2406_075_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	076	0	1	04	01	H2406_076_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	078	0	1	04	01	H2406_078_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	087	0	1	04	01	H2406_087_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	089	0	1	04	01	H2406_089_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	090	0	1	04	01	H2406_090_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	091	0	1	04	01	H2406_091_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	093	0	1	04	01	H2406_093_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	094	0	1	04	01	H2406_094_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	096	0	1	04	01	H2406_096_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	097	0	1	04	01	H2406_097_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	098	0	1	04	01	H2406_098_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	101	0	1	04	01	H2406_101_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	104	0	1	04	01	H2406_104_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	110	0	1	04	01	H2406_110_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	112	0	1	04	01	H2406_112_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	113	0	1	04	01	H2406_113_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2406	119	0	1	04	01	H2406_119_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2462	027	0	1	18	06	H2462_027_0	6																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to once per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2		500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2462	028	0	1	18	06	H2462_028_0	8																			2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to once per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2		500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided.  Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	001	0	1	02	01	H2593_001_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	001	0	1	02	01	H2593_001_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	001	0	1	02	01	H2593_001_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	003	0	1	01	01	H2593_003_0	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	003	0	1	01	01	H2593_003_0	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	003	0	1	01	01	H2593_003_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	005	0	1	02	01	H2593_005_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	005	0	1	02	01	H2593_005_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	005	0	1	02	01	H2593_005_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	006	0	1	02	01	H2593_006_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	006	0	1	02	01	H2593_006_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	006	0	1	02	01	H2593_006_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	029	0	1	02	01	H2593_029_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	029	0	1	02	01	H2593_029_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	029	0	1	02	01	H2593_029_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	040	0	1	02	01	H2593_040_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	040	0	1	02	01	H2593_040_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	040	0	1	02	01	H2593_040_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2593	043	0	1	02	01	H2593_043_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H2593	043	0	1	02	01	H2593_043_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H2593	043	0	1	02	01	H2593_043_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H2802	001	0	1	02	01	H2802_001_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	007	0	1	02	01	H2802_007_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	008	0	1	02	01	H2802_008_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	010	0	1	02	01	H2802_010_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	028	0	1	02	01	H2802_028_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	030	0	1	02	01	H2802_030_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	048	0	1	02	01	H2802_048_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	054	0	1	02	01	H2802_054_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	059	0	1	02	01	H2802_059_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	063	0	1	02	01	H2802_063_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	068	0	1	02	01	H2802_068_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	070	0	1	02	01	H2802_070_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	071	0	1	02	01	H2802_071_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H2802	076	0	1	02	01	H2802_076_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3138	001	0	1	04	01	H3138_001_0	6								2			2							2																																																																																																																1	2	2	1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3138	002	0	1	04	01	H3138_002_0	6								2			2							2																																																																																																																1	2	2	1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3138	003	0	1	04	01	H3138_003_0	6								2			2							2																																																																																																																1	2	2	1000.00	3		2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3152	048	0	1	01	01	H3152_048_0	4																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3152	082	0	1	01	01	H3152_082_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3152	098	0	1	01	01	H3152_098_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3204	001	0	1	01	01	H3204_001_0	5																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	007	0	1	01	01	H3204_007_0	5																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	008	0	1	01	01	H3204_008_0	3																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3204	017	0	1	01	01	H3204_017_0	6																																																																																																																																		1	2		4000.00	3		2					2		3	1				3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H3312	002	0	1	01	01	H3312_002_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	048	0	1	01	01	H3312_048_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	062	0	1	01	01	H3312_062_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	064	0	1	01	01	H3312_064_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	074	0	1	01	01	H3312_074_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	081	0	1	01	01	H3312_081_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	082	0	1	01	01	H3312_082_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3312	097	0	1	01	01	H3312_097_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H3335	015	0	1	04	01	H3335_015_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	018	0	1	04	01	H3335_018_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	038	0	1	04	01	H3335_038_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	043	0	1	04	01	H3335_043_0	7								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	044	0	1	04	01	H3335_044_0	7								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	053	0	1	04	01	H3335_053_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	055	0	1	04	01	H3335_055_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3335	061	0	1	04	01	H3335_061_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3335	062	0	1	04	01	H3335_062_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	006	0	1	02	01	H3351_006_0	8								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	007	0	1	02	01	H3351_007_0	7								1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H3351	022	0	1	01	01	H3351_022_0	7																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3351	023	0	1	01	01	H3351_023_0	7																																																																																																																																		1	2		1000.00	3		2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	2	2	3		2				2				2	2	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H3379	001	0	1	02	01	H3379_001_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	043	0	1	02	01	H3379_043_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	053	0	1	02	01	H3379_053_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	054	0	1	02	01	H3379_054_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	056	0	1	02	01	H3379_056_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3379	059	0	1	02	01	H3379_059_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	001	0	1	04	01	H3418_001_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	002	0	1	04	01	H3418_002_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	004	0	1	04	01	H3418_004_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3418	008	0	1	04	01	H3418_008_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3443	005	0	1	01	01	H3443_005_0	11	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3447	013	0	1	02	01	H3447_013_0	5	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	013	0	1	02	01	H3447_013_0	5	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	013	0	1	02	01	H3447_013_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	024	0	1	02	01	H3447_024_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	024	0	1	02	01	H3447_024_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	024	0	1	02	01	H3447_024_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	025	0	1	02	01	H3447_025_0	5	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	025	0	1	02	01	H3447_025_0	5	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	025	0	1	02	01	H3447_025_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	033	0	1	02	01	H3447_033_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	033	0	1	02	01	H3447_033_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	033	0	1	02	01	H3447_033_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	037	0	1	02	01	H3447_037_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	037	0	1	02	01	H3447_037_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	037	0	1	02	01	H3447_037_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	038	1	1	02	01	H3447_038_1	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	038	1	1	02	01	H3447_038_1	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	038	1	1	02	01	H3447_038_1	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	038	2	1	02	01	H3447_038_2	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	038	2	1	02	01	H3447_038_2	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	038	2	1	02	01	H3447_038_2	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	039	0	1	02	01	H3447_039_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	039	0	1	02	01	H3447_039_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	039	0	1	02	01	H3447_039_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	1	1	02	01	H3447_042_1	7	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	1	1	02	01	H3447_042_1	7	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	1	1	02	01	H3447_042_1	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	2	1	02	01	H3447_042_2	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	2	1	02	01	H3447_042_2	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	2	1	02	01	H3447_042_2	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	3	1	02	01	H3447_042_3	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	3	1	02	01	H3447_042_3	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	3	1	02	01	H3447_042_3	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	042	4	1	02	01	H3447_042_4	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	042	4	1	02	01	H3447_042_4	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	042	4	1	02	01	H3447_042_4	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	049	0	1	02	01	H3447_049_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	049	0	1	02	01	H3447_049_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	049	0	1	02	01	H3447_049_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	050	0	1	02	01	H3447_050_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	050	0	1	02	01	H3447_050_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	050	0	1	02	01	H3447_050_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	051	0	1	02	01	H3447_051_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	051	0	1	02	01	H3447_051_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	051	0	1	02	01	H3447_051_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	052	0	1	02	01	H3447_052_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	052	0	1	02	01	H3447_052_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	052	0	1	02	01	H3447_052_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3447	056	0	1	02	01	H3447_056_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3447	056	0	1	02	01	H3447_056_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3447	056	0	1	02	01	H3447_056_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3528	011	1	1	02	01	H3528_011_1	13																																																																																																																																		1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	011	1	1	02	01	H3528_011_1	13																																																																																																																																		1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	011	1	1	02	01	H3528_011_1	13	2	2	2	2	2	2	2												1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3528	011	2	1	02	01	H3528_011_2	13																																																																																																																																		1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	011	2	1	02	01	H3528_011_2	13																																																																																																																																		1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	011	2	1	02	01	H3528_011_2	13	2	2	2	2	2	2	2												1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3528	015	0	1	02	01	H3528_015_0	13																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	015	0	1	02	01	H3528_015_0	13																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	015	0	1	02	01	H3528_015_0	13																			1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3528	016	0	1	02	01	H3528_016_0	14																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		2000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	001
H3528	016	0	1	02	01	H3528_016_0	14																			2					2				2					2					2		3	2	1	4		2				2				2	2	3	2	1	6	Standard x-ray: 1 every 6 monthsIntraoral complete series, panoramic and vertical bitewings: 1 every 36 months	2				2				2	2	3	1				2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	3	2	1	4		2				2				2	2	1	2		3000.00	3		2					1	100.00	3	2	1	6	Filings - 1 every 24 monthsInlay/Onlay and single crown restoration - 1 every 60 months	3		20	50	2				1	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				1	2	3	2	1	6	Scaling and root planing - 1 every 36 months per quadrantGingivectomy, gingivoplasty, gingival flap procedures 1 every 36 months per quadrantOsseous surgery  1 every 60 months per quadrant	1	50	50	50	2				1	2	3	2	1	6	Repair of dentures - 1 per arch per 12 monthsAjustment of dentures - 2 per 12 monthsRebase or reline of dentures: 1 every 36 monthsComplete /partial Dentures  1 per arch per 60 months	1	50	50	50	2				1	2																3	2	1	6	Recement - 1 every 6 months per toothRepair - 1 every 24 months per toothImplants - 1 every 60 months per tooth	1	50	50	50	2				1	2	3	2	1	6	1 every 60 months	1	50	50	50	2				1	2	3	2	1	6	Non-bony extractions, alveloplasty with extractions - 1 per lifetimeBony extractions, vestibuloplasty - 1 per lifetimeSurgical excisions, surgical incisions - unlimited	1	50	50	50	2				1	2																3	1				2				2				1	2	002
H3528	016	0	1	02	01	H3528_016_0	14																			1		3500.00	3		2				2					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	1	1					2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	003
H3533	027	0	1	01	01	H3533_027_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H3655	041	0	1	02	01	H3655_041_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	041	0	1	02	01	H3655_041_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	041	0	1	02	01	H3655_041_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	1	1	02	01	H3655_045_1	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	1	1	02	01	H3655_045_1	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	1	1	02	01	H3655_045_1	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	2	1	02	01	H3655_045_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	2	1	02	01	H3655_045_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	2	1	02	01	H3655_045_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	3	1	02	01	H3655_045_3	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	3	1	02	01	H3655_045_3	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	3	1	02	01	H3655_045_3	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3655	045	4	1	02	01	H3655_045_4	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H3655	045	4	1	02	01	H3655_045_4	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H3655	045	4	1	02	01	H3655_045_4	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H3660	028	0	1	02	01	H3660_028_0	6								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	029	0	1	02	01	H3660_029_0	7								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	044	0	1	01	01	H3660_044_0	7								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	050	0	1	01	01	H3660_050_0	7								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	052	1	1	01	01	H3660_052_1	6								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period, once per 5-year period or once per lifetime.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	052	2	1	01	01	H3660_052_2	6								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	053	1	1	01	01	H3660_053_1	6								2	2		2					2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Periodontal surgical procedures are payable once per 36-month period.	1	50	50	50	2				2	2																																																													3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	053	2	1	01	01	H3660_053_2	5								2	2		2					2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Periodontal surgical procedures are payable once per 36-month period.	1	50	50	50	2				2	2																																																													3	2	1	6	Some services are covered once per tooth per lifetime and others are unlimited.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3660	057	0	1	01	01	H3660_057_0	6								2	2			2			2	2		2																																																																																																																2						2					2		3	2	1	6	Some services are once per tooth per 2 calendar years and some are once per five year period.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per quadrant per 24-month period, once per 36-month, or once per lifetime.	1	50	50	50	2				2	2	3	2	1	6	Some services are covered once or twice per 36-month period or once per 5-year period.	1	50	50	50	2				2	2																															3	2	1	6	As needed	1	50	50	50	2				2	2	3	2	1	6	Some services are once per tooth per lifetime, and some are once per 12 months.	1	50	50	50	2				2	2																3	2	1	6	Some services are once per lifetime or unlimited.	1	50	50	50	2				2	2	001
H3668	013	0	1	01	01	H3668_013_0	5	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	013	0	1	01	01	H3668_013_0	5	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	018	1	1	01	01	H3668_018_1	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	018	1	1	01	01	H3668_018_1	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	018	2	1	01	01	H3668_018_2	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	018	2	1	01	01	H3668_018_2	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Space maintainer benefit is for 1 per consecutive 60 months, re-cement or re-bond of space maintainer is for 1 per consecutive 6 months, or removal of fixed space maintainer is unlimited.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	019	1	1	01	01	H3668_019_1	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	019	1	1	01	01	H3668_019_1	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	019	2	1	01	01	H3668_019_2	8	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	019	2	1	01	01	H3668_019_2	8	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	020	0	1	01	01	H3668_020_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	020	0	1	01	01	H3668_020_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	022	0	1	01	01	H3668_022_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	022	0	1	01	01	H3668_022_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	023	0	1	01	01	H3668_023_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	023	0	1	01	01	H3668_023_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	025	0	1	01	01	H3668_025_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	025	0	1	01	01	H3668_025_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	026	0	1	01	01	H3668_026_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	026	0	1	01	01	H3668_026_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3668	029	0	1	01	01	H3668_029_0	4	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3668	029	0	1	01	01	H3668_029_0	4	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3672	013	0	1	01	01	H3672_013_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	014	0	1	01	01	H3672_014_0	4								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	020	0	1	01	01	H3672_020_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	021	0	1	01	01	H3672_021_0	4								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	023	0	1	01	01	H3672_023_0	5								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years.	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3672	024	0	1	01	01	H3672_024_0	4								2	2	2	2	2			2	2																																																																																																																		1	2		1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	75	2				2	2	3	1				3		50	75	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	3		50	75	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	3		50	75	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	3		50	75	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	3		50	75	2				2	2																															001
H3805	015	0	1	02	01	H3805_015_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	017	0	1	02	01	H3805_017_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	032	0	1	02	01	H3805_032_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	033	0	1	02	01	H3805_033_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	034	0	1	02	01	H3805_034_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	037	0	1	02	01	H3805_037_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	039	1	1	02	01	H3805_039_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	039	2	1	02	01	H3805_039_2	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	040	0	1	02	01	H3805_040_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3805	043	0	1	02	01	H3805_043_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H3815	001	0	1	01	01	H3815_001_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	008	0	1	01	01	H3815_008_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	010	0	1	01	01	H3815_010_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	011	0	1	01	01	H3815_011_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	013	0	1	01	01	H3815_013_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	019	0	1	01	01	H3815_019_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	020	0	1	01	01	H3815_020_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	021	0	1	01	01	H3815_021_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	023	0	1	01	01	H3815_023_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	028	0	1	01	01	H3815_028_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	031	0	1	01	01	H3815_031_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	033	0	1	01	01	H3815_033_0	6	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	034	0	1	01	01	H3815_034_0	7																			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	035	0	1	01	01	H3815_035_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	038	0	1	01	01	H3815_038_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	040	0	1	01	01	H3815_040_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	047	0	1	01	01	H3815_047_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				2				3		20.00	425.00	2	2																															3	1				2				3		40.00	425.00	2	2	3	1				1	50	50	50	2				2	2																															001
H3815	048	0	1	01	01	H3815_048_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	054	0	1	01	01	H3815_054_0	8	2	2	2		2	2		2	2	2	2	2			2	2			1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H3815	055	0	1	01	01	H3815_055_0	7	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																															001
H3815	056	0	1	01	01	H3815_056_0	7	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				2				2				2	2																															3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																															001
H3822	001	0	1	01	01	H3822_001_0	6								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H3822	007	0	1	02	01	H3822_007_0	6								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H3828	001	0	1	04	01	H3828_001_0	6	2			2			2	2	2	2	2					2		2	1	2	500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H3828	001	0	1	04	01	H3828_001_0	6	2			2			2	2	2	2	2					2		2	1	2	1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H3890	001	0	1	04	01	H3890_001_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H3890	002	0	1	04	01	H3890_002_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for benefit details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H3890	005	0	1	04	01	H3890_005_0	10																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	3	2	1	6	Frequency of services:  Root canals and retreatment, apicoectomy, clinical crown lenghtening-once per tooth per lifetime	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Gingivectomy, gingivoplasty, gingival flap procedure, osseous surgery, periodontal scaling and root planning - once per quadrant per 3 years Full mouth debridement - once per 3 years Clinical crown lengthening-hard tissue - 1 per permanent tooth per lifetime	2				1	50.00	50.00	50.00	1	2	3	2	1	6	 Complete or immediate denture - 1 per 5 years  Adjustment of dentures - 2 per year after 6 months of initial placement Repair dentures and replace/add teeth - once per tooth per year Rebase or reline dentures - 1 per 3 years after 6 months of initial placement Tissue conditioning	2				3		50.00	100.00	1	2																3	2	1	6	 Implants - one per 5 years per tooth Re-cement implants - once every 2 years after 6 months of initial placement	2				1	100.00	100.00	100.00	1	2	3	2	1	6	 Partial denture - one every 5 years Re-cement or re-bond fixed partial denture repair, partial fixed dentures - once every 2 years after 6 months of initial placement	2				3		50.00	100.00	1	2	3	2	1	6	See notes for details	2				3		50.00	100.00	1	2																3	2	1	6	See notes for details	2				1	50.00	50.00	50.00	1	2	001
H3924	059	21	1	04	01	H3924_059_21	3																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3924	059	22	1	04	01	H3924_059_22	3																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3924	065	0	1	04	01	H3924_065_0	3																			1	2	1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	1				2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																																														3	1				2				2				2	2																3	1				2				2				2	2	001
H3979	001	0	1	01	01	H3979_001_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	5	2	2	2		2	2													1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	008	0	1	04	01	H4036_008_0	5	2	2	2		2	2													1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	008	0	1	04	01	H4036_008_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	017	0	1	04	01	H4036_017_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	017	0	1	04	01	H4036_017_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	017	0	1	04	01	H4036_017_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	022	0	1	04	01	H4036_022_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	022	0	1	04	01	H4036_022_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	022	0	1	04	01	H4036_022_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	024	0	1	04	01	H4036_024_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	024	0	1	04	01	H4036_024_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	024	0	1	04	01	H4036_024_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	025	0	1	04	01	H4036_025_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	025	0	1	04	01	H4036_025_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	025	0	1	04	01	H4036_025_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	026	0	1	04	01	H4036_026_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	026	0	1	04	01	H4036_026_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	026	0	1	04	01	H4036_026_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	030	0	1	04	01	H4036_030_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	030	0	1	04	01	H4036_030_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	030	0	1	04	01	H4036_030_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	034	0	1	04	01	H4036_034_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	034	0	1	04	01	H4036_034_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	034	0	1	04	01	H4036_034_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	036	0	1	04	01	H4036_036_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	036	0	1	04	01	H4036_036_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	036	0	1	04	01	H4036_036_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4036	040	0	1	04	01	H4036_040_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4036	040	0	1	04	01	H4036_040_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4036	040	0	1	04	01	H4036_040_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4141	022	0	1	01	01	H4141_022_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H4161	002	0	1	02	01	H4161_002_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	002	0	1	02	01	H4161_002_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	002	0	1	02	01	H4161_002_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	004	0	1	02	01	H4161_004_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	004	0	1	02	01	H4161_004_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	004	0	1	02	01	H4161_004_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	005	0	1	02	01	H4161_005_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	005	0	1	02	01	H4161_005_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	005	0	1	02	01	H4161_005_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	006	0	1	02	01	H4161_006_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	006	0	1	02	01	H4161_006_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	006	0	1	02	01	H4161_006_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	007	0	1	02	01	H4161_007_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	007	0	1	02	01	H4161_007_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	007	0	1	02	01	H4161_007_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	009	0	1	02	01	H4161_009_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	009	0	1	02	01	H4161_009_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	009	0	1	02	01	H4161_009_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	010	0	1	02	01	H4161_010_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	010	0	1	02	01	H4161_010_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	010	0	1	02	01	H4161_010_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	011	0	1	02	01	H4161_011_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	011	0	1	02	01	H4161_011_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	011	0	1	02	01	H4161_011_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	012	0	1	02	01	H4161_012_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	012	0	1	02	01	H4161_012_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	012	0	1	02	01	H4161_012_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	013	0	1	02	01	H4161_013_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	013	0	1	02	01	H4161_013_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	013	0	1	02	01	H4161_013_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	014	0	1	02	01	H4161_014_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	014	0	1	02	01	H4161_014_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	014	0	1	02	01	H4161_014_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	015	0	1	02	01	H4161_015_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	015	0	1	02	01	H4161_015_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	015	0	1	02	01	H4161_015_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	016	0	1	02	01	H4161_016_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	016	0	1	02	01	H4161_016_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	016	0	1	02	01	H4161_016_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4161	017	0	1	02	01	H4161_017_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4161	017	0	1	02	01	H4161_017_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4161	017	0	1	02	01	H4161_017_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	001	0	1	02	01	H4346_001_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	001	0	1	02	01	H4346_001_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	001	0	1	02	01	H4346_001_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	005	0	1	02	01	H4346_005_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	005	0	1	02	01	H4346_005_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	005	0	1	02	01	H4346_005_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	006	0	1	02	01	H4346_006_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	006	0	1	02	01	H4346_006_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	006	0	1	02	01	H4346_006_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	010	0	1	01	01	H4346_010_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	010	0	1	01	01	H4346_010_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	010	0	1	01	01	H4346_010_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	012	0	1	01	01	H4346_012_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	012	0	1	01	01	H4346_012_0	7																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	012	0	1	01	01	H4346_012_0	7																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	017	0	1	02	01	H4346_017_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	017	0	1	02	01	H4346_017_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	017	0	1	02	01	H4346_017_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4346	030	0	1	02	01	H4346_030_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4346	030	0	1	02	01	H4346_030_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4346	030	0	1	02	01	H4346_030_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4497	001	1	1	04	01	H4497_001_1	15																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	001	3	1	04	01	H4497_001_3	15																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	1	1	04	01	H4497_002_1	15																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	002	3	1	04	01	H4497_002_3	15																			1	2	1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H4497	005	3	1	04	01	H4497_005_3	14	2			2				2	1	1	1	1		1	1	2		1	1	2	1000.00	3		2														2																																3	1				2				2				2	2																																														1	1					2					2																																																																																																											3	1				2				2				2	2																															001
H4497	005	4	1	04	01	H4497_005_4	14	2			2				2	1	1	1	1		1	1	2		1	1	2	1000.00	3		2														2																																3	1				2				2				2	2																																														1	1					2					2																																																																																																											3	1				2				2				2	2																															001
H4514	007	0	1	02	01	H4514_007_0	4	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	002	0	1	02	01	H4527_002_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	024	0	1	02	01	H4527_024_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	037	0	1	02	01	H4527_037_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	039	0	1	02	01	H4527_039_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	048	0	1	02	01	H4527_048_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	051	0	1	02	01	H4527_051_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4527	053	0	1	02	01	H4527_053_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4544	001	0	1	04	01	H4544_001_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	011	0	1	02	01	H4604_011_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	016	0	1	02	01	H4604_016_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	017	0	1	02	01	H4604_017_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	020	0	1	02	01	H4604_020_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	022	0	1	02	01	H4604_022_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	024	0	1	02	01	H4604_024_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4604	025	0	1	02	01	H4604_025_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H4875	016	1	1	04	01	H4875_016_1	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	2	1	04	01	H4875_016_2	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	3	1	04	01	H4875_016_3	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	4	1	04	01	H4875_016_4	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	016	5	1	04	01	H4875_016_5	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	1	1	04	01	H4875_018_1	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	2	1	04	01	H4875_018_2	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	3	1	04	01	H4875_018_3	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	4	1	04	01	H4875_018_4	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	018	5	1	04	01	H4875_018_5	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2																															3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for bridges every 5 years and bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	020	1	1	04	01	H4875_020_1	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	020	2	1	04	01	H4875_020_2	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	020	3	1	04	01	H4875_020_3	6	2		2		2			2								2			2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Crowns, onlays and associated substructures once every 60 months, crown repairs every 12 months and fillings once in any 2 year period, same tooth, same surface. Full description in notes.	3		0	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	Coverage for  bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Simple and surgical extractions are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	022	1	1	04	01	H4875_022_1	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	022	2	1	04	01	H4875_022_2	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	022	5	1	04	01	H4875_022_5	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes.	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	024	1	1	04	01	H4875_024_1	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4875	024	2	1	04	01	H4875_024_2	6	2		2		2			2	2							2		2	2					2				2					2					2																	3	1				1	50	50	50	2				2	2																3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																1	2	2	2500.00	3		2					2		3	2	1	6	Every 60 months, full description of services in notes	1	50	50	50	2				2	2	3	2	1	6	Root canals are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	6	Complete or partial dentures can be done every 5 years and denture relines and repairs every 36 months.	1	50	50	50	2				2	2																3	2	1	6	Implant and implant related services (once per tooth every 5 years)	1	50	50	50	2				2	2	3	2	1	6	bridge relines and repairs every 36 months.	1	50	50	50	2				2	2	3	2	1	6	Surgical extractions are covered once per tooth per lifetime	1	50	50	50	2				2	2																3	1				2				2				2	2	001
H4882	003	0	1	04	01	H4882_003_0	8	2	2	2	2	2	2	2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	009	1	1	04	01	H4882_009_1	11	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	009	2	1	04	01	H4882_009_2	10	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	011	1	1	04	01	H4882_011_1	9	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	011	2	1	04	01	H4882_011_2	8	2	2	2	2	2	2	2	2	2		2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	014	1	1	04	01	H4882_014_1	7	2	2	2	2	2	2	2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	2	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4882	014	2	1	04	01	H4882_014_2	6	2	2	2	2	2	2	2	2			2								2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	Bitewings limited to 1 per year. Full-mouth & panoramic x-rays limited to 1 every 3 years. Limits combined INN/OON. All other diagnostic x-rays unlimited.	2				2				2	2	3	2	2	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	6	Space maintainers are unlimited, oral hygiene instruction  limited to once per lifetime, sealants limited to one per tooth every 3 years for permanent molars. Limits combined INN/OON.	3		0	50	2				2	2	1	2	2	500.00	3		2					2		3	2	1	6	Replacement of crown, inlay, or onlay only after 5 year period measured from the date on which the procedure was last provided. Amalgam and resin-based composite fillings are unlimited.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	2	2		3		0	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2																3	2	1	6	Replacement of existing implant-supported prosthesis only after 5 year period measured from the date on which the existing implant was installed.	1	50	50	50	2				2	2	3	2	1	6	Replacement of or addition of teeth to the existing prosthetic only after 5 year period measured from the date on which the prosthetic was installed.	1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	014	0	1	04	01	H4909_014_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	014	0	1	04	01	H4909_014_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	014	0	1	04	01	H4909_014_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	020	0	1	04	01	H4909_020_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	020	0	1	04	01	H4909_020_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	020	0	1	04	01	H4909_020_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	021	0	1	04	01	H4909_021_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	021	0	1	04	01	H4909_021_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	021	0	1	04	01	H4909_021_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	023	0	1	04	01	H4909_023_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	023	0	1	04	01	H4909_023_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	023	0	1	04	01	H4909_023_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4909	026	0	1	04	01	H4909_026_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H4909	026	0	1	04	01	H4909_026_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H4909	026	0	1	04	01	H4909_026_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H4961	001	0	1	04	01	H4961_001_0	7																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H4961	003	0	1	04	01	H4961_003_0	7																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H4961	006	0	1	04	01	H4961_006_0	8	2	2	2		2	2													1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H5050	001	0	1	01	01	H5050_001_0	3								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	004	0	1	01	01	H5050_004_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	009	0	1	01	01	H5050_009_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	017	0	1	01	01	H5050_017_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	019	0	1	01	01	H5050_019_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	021	0	1	01	01	H5050_021_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	022	0	1	01	01	H5050_022_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	023	0	1	01	01	H5050_023_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	024	0	1	01	01	H5050_024_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	025	0	1	01	01	H5050_025_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	026	0	1	01	01	H5050_026_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	027	0	1	01	01	H5050_027_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	028	0	1	01	01	H5050_028_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	029	0	1	01	01	H5050_029_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	030	0	1	01	01	H5050_030_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	031	0	1	01	01	H5050_031_0	4																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5050	032	0	1	01	01	H5050_032_0	4								2			2							2																																																																																																																2						2					1	100.00	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5211	001	0	1	02	01	H5211_001_0	9	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray. Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		0	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	002	0	1	02	01	H5211_002_0	10	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		0	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	003	0	1	02	01	H5211_003_0	9	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		0	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	004	0	1	02	01	H5211_004_0	11	2	2	2		2														2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	6	Bitewing X-rays are covered once per calendar year, except in years when you get the full-mouth or panoramic X-ray.Either a full-mouth X-ray or panoramic X-ray is covered once every five years.	2				2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		0	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	010	0	1	01	01	H5211_010_0	11	2	1	1	2	1	2		2	2	2	2	2		2	2	2		2	2					2				2					2					2																																3	1				1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2																2						2					2		3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				3		0	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		20	50	2				2	2	001
H5211	012	0	1	02	01	H5211_012_0	11	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5215	002	0	1	04	01	H5215_002_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	005	0	1	04	01	H5215_005_0	5	2	2			2														2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	008	0	1	04	01	H5215_008_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	009	0	1	04	01	H5215_009_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5215	012	0	1	04	01	H5215_012_0	5	2	2	2	2	2	2	2	2	2	2	2	2	2		2	2		2	2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	001
H5216	013	0	1	04	01	H5216_013_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	017	0	1	04	01	H5216_017_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	019	0	1	04	01	H5216_019_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	023	0	1	04	01	H5216_023_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	027	0	1	04	01	H5216_027_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	034	0	1	04	01	H5216_034_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	037	0	1	04	01	H5216_037_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	063	0	1	04	01	H5216_063_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	064	0	1	04	01	H5216_064_0	5	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	073	0	1	04	01	H5216_073_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	078	1	1	04	01	H5216_078_1	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	078	6	1	04	01	H5216_078_6	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	089	0	1	04	01	H5216_089_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	092	0	1	04	01	H5216_092_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	100	0	1	04	01	H5216_100_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	116	0	1	04	01	H5216_116_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	138	0	1	04	01	H5216_138_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	144	0	1	04	01	H5216_144_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	154	0	1	04	01	H5216_154_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	168	0	1	04	01	H5216_168_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	192	0	1	04	01	H5216_192_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	194	0	1	04	01	H5216_194_0	2	2	2	2	2	2		2	2	2									2	2					2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	2						2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	211	0	1	04	01	H5216_211_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	234	0	1	04	01	H5216_234_0	2	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	286	0	1	04	01	H5216_286_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	289	0	1	04	01	H5216_289_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	308	0	1	04	01	H5216_308_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	309	0	1	04	01	H5216_309_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	310	0	1	04	01	H5216_310_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	322	0	1	04	01	H5216_322_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	343	0	1	04	01	H5216_343_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	345	0	1	04	01	H5216_345_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	359	0	1	04	01	H5216_359_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	376	0	1	04	01	H5216_376_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	379	0	1	04	01	H5216_379_0	2	2	2	2	2	2		2	2	2									2	1	2	750.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	383	0	1	04	01	H5216_383_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	389	0	1	04	01	H5216_389_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	395	0	1	04	01	H5216_395_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	406	0	1	04	01	H5216_406_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	429	0	1	04	01	H5216_429_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	430	0	1	04	01	H5216_430_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	433	0	1	04	01	H5216_433_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	442	0	1	04	01	H5216_442_0	2	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	461	0	1	04	01	H5216_461_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	464	0	1	04	01	H5216_464_0	4	2	2	2	2	2		2	2	2									2	2					2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	2						2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	465	0	1	04	01	H5216_465_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5216	466	0	1	04	01	H5216_466_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5253	034	0	1	02	01	H5253_034_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	035	0	1	02	01	H5253_035_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	039	0	1	02	01	H5253_039_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	040	0	1	02	01	H5253_040_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	062	0	1	02	01	H5253_062_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	072	0	1	02	01	H5253_072_0	7	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	079	0	1	02	01	H5253_079_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	097	0	1	02	01	H5253_097_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	099	0	1	02	01	H5253_099_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	103	0	1	02	01	H5253_103_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	108	2	1	02	01	H5253_108_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	110	0	1	02	01	H5253_110_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	119	0	1	02	01	H5253_119_0	4	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	120	0	1	02	01	H5253_120_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	125	1	1	02	01	H5253_125_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	127	0	1	02	01	H5253_127_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	135	0	1	02	01	H5253_135_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	142	0	1	02	01	H5253_142_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	144	1	1	02	01	H5253_144_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	144	2	1	02	01	H5253_144_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	154	0	1	02	01	H5253_154_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	155	0	1	02	01	H5253_155_0	7	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	157	1	1	02	01	H5253_157_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	157	2	1	02	01	H5253_157_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	159	0	1	02	01	H5253_159_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	161	0	1	02	01	H5253_161_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	162	1	1	02	01	H5253_162_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	162	2	1	02	01	H5253_162_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	169	0	1	02	01	H5253_169_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	173	0	1	02	01	H5253_173_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	175	0	1	02	01	H5253_175_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	176	0	1	02	01	H5253_176_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	179	0	1	02	01	H5253_179_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	180	0	1	02	01	H5253_180_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	182	0	1	02	01	H5253_182_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	183	0	1	02	01	H5253_183_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	186	0	1	02	01	H5253_186_0	11	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	188	0	1	02	01	H5253_188_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	189	0	1	02	01	H5253_189_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	192	0	1	02	01	H5253_192_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	193	1	1	02	01	H5253_193_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	195	0	1	02	01	H5253_195_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	197	0	1	02	01	H5253_197_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	198	0	1	02	01	H5253_198_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	202	0	1	02	01	H5253_202_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	207	0	1	02	01	H5253_207_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	208	0	1	02	01	H5253_208_0	4	2							2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5253	209	0	1	02	01	H5253_209_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5262	001	0	1	01	01	H5262_001_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	003	0	1	01	01	H5262_003_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	004	0	1	01	01	H5262_004_0	3	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	005	0	1	01	01	H5262_005_0	3	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	007	0	1	01	01	H5262_007_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	008	0	1	01	01	H5262_008_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	009	0	1	01	01	H5262_009_0	3	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	010	0	1	01	01	H5262_010_0	3	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	021	0	1	01	01	H5262_021_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	023	0	1	01	01	H5262_023_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H5262	032	0	1	01	01	H5262_032_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H5262	033	0	1	01	01	H5262_033_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
H5296	006	0	1	01	01	H5296_006_0	10	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5296	008	0	1	01	01	H5296_008_0	8	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5322	040	0	1	02	01	H5322_040_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5322	043	0	1	02	01	H5322_043_0	3	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5322	047	1	1	02	01	H5322_047_1	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5322	047	2	1	02	01	H5322_047_2	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5386	003	0	1	01	01	H5386_003_0	7																			2					2				2					2					2		3	1				2				3		0.00	5.00	1	1	3	2	1	4		2				2				1	1	3	1				2				3		0.00	5.00	1	1	3	2	1	4		2				1	15.00	15.00	15.00	1	1																3	1				2				3		0.00	150.00	1	1	2						2					2		3	1				2				3		20.00	425.00	1	1	3	1				2				3		0.00	475.00	1	1	3	1				2				3		0.00	450.00	1	1	3	1				2				3		20.00	495.00	1	1																															3	1				2				3		30.00	425.00	1	1	3	1				2				3		0.00	65.00	1	1																3	1				2				3		0.00	50.00	1	1	001
H5386	003	0	1	01	01	H5386_003_0	7																			2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	002
H5386	004	0	1	01	01	H5386_004_0	8	2	2	2	2	2		2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	001
H5386	005	0	1	01	01	H5386_005_0	8	2	2	2	2	2		2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	001
H5386	006	0	1	01	01	H5386_006_0	8	2	2	2	2	2		2	2	2	2	2	2			2	2		2	2					2				2					2					2		3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				2				2	2	3	1				2				3		0.00	5.00	2	2	3	2	1	4		2				1	15.00	15.00	15.00	2	2																3	1				2				3		0.00	150.00	2	2	1	2		3000.00	3		2					2		3	1				2				3		20.00	425.00	2	2	3	1				2				3		0.00	475.00	2	2	3	1				2				3		0.00	450.00	2	2	3	1				2				3		20.00	495.00	2	2																															3	1				2				3		30.00	425.00	2	2	3	1				2				3		0.00	65.00	2	2																3	1				2				3		0.00	50.00	2	2	001
H5422	011	0	1	02	01	H5422_011_0	4	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	011	0	1	02	01	H5422_011_0	4	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	011	0	1	02	01	H5422_011_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5422	014	0	1	02	01	H5422_014_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	014	0	1	02	01	H5422_014_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	014	0	1	02	01	H5422_014_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5422	015	0	1	02	01	H5422_015_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5422	015	0	1	02	01	H5422_015_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5422	015	0	1	02	01	H5422_015_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5425	001	0	1	01	01	H5425_001_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	005	0	1	01	01	H5425_005_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	006	0	1	01	01	H5425_006_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	007	0	1	01	01	H5425_007_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	008	0	1	01	01	H5425_008_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	009	0	1	01	01	H5425_009_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	034	0	1	01	01	H5425_034_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	082	0	1	01	01	H5425_082_0	6	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	086	0	1	01	01	H5425_086_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	087	0	1	01	01	H5425_087_0	9	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	091	0	1	02	01	H5425_091_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	092	0	1	01	01	H5425_092_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	096	0	1	01	01	H5425_096_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	104	0	1	01	01	H5425_104_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	105	0	1	01	01	H5425_105_0	8	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5425	134	0	1	01	01	H5425_134_0	7	1	1	1	1	1		1	1	1	1	1	1			1	1		1																																																																																																																																																																																																																																																																																			001
H5472	003	0	1	02	01	H5472_003_0	10	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5472	010	0	1	02	01	H5472_010_0	7	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H5521	077	0	1	04	01	H5521_077_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	120	0	1	04	01	H5521_120_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	121	0	1	04	01	H5521_121_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	123	0	1	04	01	H5521_123_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	124	0	1	04	01	H5521_124_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	215	0	1	04	01	H5521_215_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	277	0	1	04	01	H5521_277_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	392	0	1	04	01	H5521_392_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	457	0	1	04	01	H5521_457_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	512	0	1	04	01	H5521_512_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	520	0	1	04	01	H5521_520_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	521	0	1	04	01	H5521_521_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	536	0	1	04	01	H5521_536_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	537	0	1	04	01	H5521_537_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	661	0	1	04	01	H5521_661_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	662	0	1	04	01	H5521_662_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	664	0	1	04	01	H5521_664_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5521	665	0	1	04	01	H5521_665_0	3																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
H5525	004	0	1	04	01	H5525_004_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	005	0	1	04	01	H5525_005_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	006	0	1	04	01	H5525_006_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	008	0	1	04	01	H5525_008_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	030	0	1	04	01	H5525_030_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	035	0	1	04	01	H5525_035_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	042	0	1	04	01	H5525_042_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	049	0	1	04	01	H5525_049_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	051	2	1	04	01	H5525_051_2	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	065	0	1	04	01	H5525_065_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	085	1	1	04	01	H5525_085_1	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5525	085	2	1	04	01	H5525_085_2	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5591	018	0	1	02	01	H5591_018_0	5	2	2			1														1		1500.00	3		2				2					1	100100	50.00	50.00	50.00	2		3	2	1	3		2								2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	1	1					2					2		3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																3	1				1	50	50	50	1	50.00	50.00	50.00	2	2	3	1				1	50	50	50	1	50.00	50.00	50.00	2	2																															001
H5619	026	0	1	01	01	H5619_026_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	059	0	1	01	01	H5619_059_0	3	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	061	0	1	01	01	H5619_061_0	3	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	066	0	1	01	01	H5619_066_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	121	0	1	01	01	H5619_121_0	4	2	2	2	2	2		2	2	2									2	2					2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	2						2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5619	145	0	1	01	01	H5619_145_0	5	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	169	0	1	01	01	H5619_169_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	173	0	1	01	01	H5619_173_0	3	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H5619	183	0	1	01	01	H5619_183_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H5652	001	0	1	02	01	H5652_001_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	002	0	1	02	01	H5652_002_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	004	0	1	02	01	H5652_004_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	006	0	1	02	01	H5652_006_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5652	008	0	1	02	01	H5652_008_0	5	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H5828	008	0	1	02	01	H5828_008_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	008	0	1	02	01	H5828_008_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	008	0	1	02	01	H5828_008_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	013	0	1	02	01	H5828_013_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	013	0	1	02	01	H5828_013_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	013	0	1	02	01	H5828_013_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	014	0	1	02	01	H5828_014_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	014	0	1	02	01	H5828_014_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	014	0	1	02	01	H5828_014_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	015	0	1	02	01	H5828_015_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	015	0	1	02	01	H5828_015_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	015	0	1	02	01	H5828_015_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	016	0	1	02	01	H5828_016_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	016	0	1	02	01	H5828_016_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	016	0	1	02	01	H5828_016_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5828	017	0	1	02	01	H5828_017_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5828	017	0	1	02	01	H5828_017_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5828	017	0	1	02	01	H5828_017_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	018	0	1	02	01	H5854_018_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	018	0	1	02	01	H5854_018_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	018	0	1	02	01	H5854_018_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	019	1	1	01	01	H5854_019_1	4																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	019	1	1	01	01	H5854_019_1	4																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	019	1	1	01	01	H5854_019_1	4																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5854	019	2	1	01	01	H5854_019_2	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H5854	019	2	1	01	01	H5854_019_2	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year)	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H5854	019	2	1	01	01	H5854_019_2	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H5883	001	1	1	02	01	H5883_001_1	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	2	1	02	01	H5883_001_2	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	3	1	02	01	H5883_001_3	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	4	1	02	01	H5883_001_4	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	001	5	1	02	01	H5883_001_5	6								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.  Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures; Denture Adjustment and repairs, Denture Reline/Rebase	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	1	1	02	01	H5883_002_1	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	2	1	02	01	H5883_002_2	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	3	1	02	01	H5883_002_3	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	4	1	02	01	H5883_002_4	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	002	7	1	02	01	H5883_002_7	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	1	1	02	01	H5883_003_1	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	2	1	02	01	H5883_003_2	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	3	1	02	01	H5883_003_3	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	4	1	02	01	H5883_003_4	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	003	5	1	02	01	H5883_003_5	7								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5883	007	0	1	01	01	H5883_007_0	8								2	2		2																																																																																																																							1	2		1500.00	3		2					2		3	2	1	6	Onlays.   Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and crowns. Implants maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H5970	028	0	1	04	01	H5970_028_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6322	001	0	1	01	01	H6322_001_0	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	001	0	1	01	01	H6322_001_0	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	002	0	1	01	01	H6322_002_0	7								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	002	0	1	01	01	H6322_002_0	7								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6322	008	0	1	01	01	H6322_008_0	8								2	2		2					2		2	2					2														2																																3	1				1	50	50	50	2				2	2																																														2						2					2		3	1				1	75	75	75	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				3		50	75	2				2	2																3	1				3		50	75	2				1	2	3	1				3		50	75	2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6322	008	0	1	01	01	H6322_008_0	8								2	2		2					2		2	2					2														2																																3	1				1	20	20	20	2				2	2																																														2						2					2		3	1				1	50	50	50	2				1	2	3	1				1	20	20	20	2				1	2	3	1				1	20	20	20	2				2	2	3	1				3		20	50	2				2	2																3	1				3		20	50	2				1	2	3	1				3		20	50	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	002
H6622	017	0	1	01	01	H6622_017_0	5	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	028	0	1	01	01	H6622_028_0	3	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	1	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	1	3	2	2	1		1	0	0	0	2				1	1	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	1																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	1	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	1																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	1	001
H6622	055	0	1	01	01	H6622_055_0	2	2	2	2	2	2		2	2	2									2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	090	0	1	01	01	H6622_090_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	095	0	1	01	01	H6622_095_0	2	2	2	2	2	2		2	2										2	1		1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6622	097	0	1	01	01	H6622_097_0	2	2	2	2	2	2		2	2	2		2							2	1		500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H6706	001	0	1	02	01	H6706_001_0	4	2	2	2		2	2	2	2											1		1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H6723	001	1	1	01	01	H6723_001_1	14	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	001	3	1	01	01	H6723_001_3	14	2			2				2	1	1	1					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																																																																																											3	1				1	30	30	30	2				2	2																															001
H6723	002	1	1	01	01	H6723_002_1	14																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	002	3	1	01	01	H6723_002_3	14																			1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	003	1	1	01	01	H6723_003_1	14	2			2				2	1	1	2					2		1	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2																																3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																															001
H6723	003	3	1	01	01	H6723_003_3	16	2			2				2	2	2	2					2		2	1		1000.00	3		2														2																																3	1				1	30	30	30	2				2	2																																														1	1					2					2		3	1				1	30	30	30	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6723	006	6	1	02	01	H6723_006_6	15	2			2				2	1	1	1	1		1	1	2		1	1		1000.00	3		2														2																																3	1				2				2				2	2																																														1	1					2					2																																																																																																											3	1				2				2				2	2																															001
H6723	006	7	1	02	01	H6723_006_7	5	2			2				2	1	1	1	1		1	1	2		1	1		1000.00	3		2														2																																3	1				2				2				2	2																																														1	1					2					2																																																																																																											3	1				2				2				2	2																															001
H6874	001	0	1	04	01	H6874_001_0	9	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					2		3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6874	003	0	1	04	01	H6874_003_0	8	2	2	2		2			2			2								2					2				2					2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2																															2						2					2		3	1				3		30	60	2				2	2	3	1				1	30	30	30	2				2	2	3	1				3		0	30	2				2	2	3	1				1	60	60	60	2				2	2																3	1				1	60	60	60	2				2	2	3	1				1	60	60	60	2				2	2	3	1				1	30	30	30	2				2	2																3	1				1	30	30	30	2				2	2	001
H6910	001	0	1	01	01	H6910_001_0	6	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H6910	001	0	1	01	01	H6910_001_0	6	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H6910	004	0	1	01	01	H6910_004_0	4	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H6910	004	0	1	01	01	H6910_004_0	4	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H6988	006	0	1	02	01	H6988_006_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	006	0	1	02	01	H6988_006_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	006	0	1	02	01	H6988_006_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	007	0	1	02	01	H6988_007_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	007	0	1	02	01	H6988_007_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	007	0	1	02	01	H6988_007_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	008	0	1	02	01	H6988_008_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	008	0	1	02	01	H6988_008_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	008	0	1	02	01	H6988_008_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	009	0	1	02	01	H6988_009_0	7	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	009	0	1	02	01	H6988_009_0	7	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	009	0	1	02	01	H6988_009_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H6988	010	0	1	02	01	H6988_010_0	5	2	2	2		2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H6988	010	0	1	02	01	H6988_010_0	5	2	2	2		2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H6988	010	0	1	02	01	H6988_010_0	5	2	2	2		2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7063	001	0	1	04	01	H7063_001_0	3								2	2	2	2	2			2	2		2																																																																																																																2						2					2		3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2																															3	2	1	3		1	50	50	50	2				2	2	3	2	1	3		1	50	50	50	2				2	2																3	2	1	3		1	50	50	50	2				2	2	001
H7063	007	0	1	04	01	H7063_007_0	3								2	2	2	2	2			2	2		2																																																																																																																2						2					2		3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																															3	2	1	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	1	3		2				2				2	2	001
H7093	001	0	1	04	01	H7093_001_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7093	001	0	1	04	01	H7093_001_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7093	001	0	1	04	01	H7093_001_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7093	002	0	1	04	01	H7093_002_0	5	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7093	002	0	1	04	01	H7093_002_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7093	002	0	1	04	01	H7093_002_0	5	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	004	0	1	02	01	H7220_004_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	004	0	1	02	01	H7220_004_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	004	0	1	02	01	H7220_004_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	009	1	1	01	01	H7220_009_1	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	1	1	01	01	H7220_009_1	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	1	1	01	01	H7220_009_1	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	009	2	1	01	01	H7220_009_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	009	2	1	01	01	H7220_009_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	009	2	1	01	01	H7220_009_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7220	010	0	1	01	01	H7220_010_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H7220	010	0	1	01	01	H7220_010_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H7220	010	0	1	01	01	H7220_010_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H7617	003	0	1	04	01	H7617_003_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	007	0	1	04	01	H7617_007_0	4	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	024	0	1	04	01	H7617_024_0	2	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	027	0	1	04	01	H7617_027_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	044	0	1	04	01	H7617_044_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	046	0	1	04	01	H7617_046_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	049	0	1	04	01	H7617_049_0	3	2	2	2	2	2		2	2	2									2	1	2	1000.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	094	0	1	04	01	H7617_094_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	096	0	1	04	01	H7617_096_0	1	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	100	0	1	04	01	H7617_100_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H7617	101	0	1	04	01	H7617_101_0	1	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
H8133	001	0	1	01	01	H8133_001_0	7																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8133	005	0	1	01	01	H8133_005_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8145	055	0	1	09	04	H8145_055_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				2	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				2	2	3	2	2	1		1	0	0	0	2				2	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				2	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				2	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				2	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				2	2	001
H8145	163	0	1	09	04	H8145_163_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				2	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				2	2	3	2	2	1		1	0	0	0	2				2	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				2	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				2	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				2	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				2	2	001
H8211	006	0	1	04	01	H8211_006_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8211	009	0	1	04	01	H8211_009_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8211	011	0	1	04	01	H8211_011_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8432	009	0	1	01	01	H8432_009_0	4																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	009	0	1	01	01	H8432_009_0	4																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	009	0	1	01	01	H8432_009_0	4																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	010	0	1	01	01	H8432_010_0	4																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	010	0	1	01	01	H8432_010_0	4																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	010	0	1	01	01	H8432_010_0	4																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	011	0	1	01	01	H8432_011_0	4																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	011	0	1	01	01	H8432_011_0	4																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	011	0	1	01	01	H8432_011_0	4																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	036	0	1	02	01	H8432_036_0	4	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	036	0	1	02	01	H8432_036_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	036	0	1	02	01	H8432_036_0	4	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8432	040	0	1	02	01	H8432_040_0	7	2	2	2		2	2													1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8432	040	0	1	02	01	H8432_040_0	7	2	2	2		2	2													1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8432	040	0	1	02	01	H8432_040_0	7	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8547	001	0	1	01	01	H8547_001_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8604	011	0	1	04	01	H8604_011_0	5																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	014	1	1	04	01	H8604_014_1	5								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	014	2	1	04	01	H8604_014_2	5								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	3		20	50	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planning 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8604	015	0	1	04	01	H8604_015_0	6								2	2	2	2	2			2	2																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	One Filling per tooth every three years.  One Crown per tooth every five years.	1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	2	1	6	Gingivectomy/gingivoplasty 1 site every 2 yrs. Scaling and root planing 1 site every 3 yrs. Periodontal maint 2 every yrs. Full mouth debridement 1 every 3 yrs. Osseous surgery 1 per site every 3 yrs	1	50	50	50	2				2	2	3	2	1	6	Dentures one set every five calendar years.  Adjust/Repair/Reline one per arch every calendar year.	1	50	50	50	2				2	2																															3	2	1	6	One crown per tooth every five calendar years	1	50	50	50	2				2	2	3	2	1	6	Extractions, Excision of lesion, Anesthesia - unlimited.  Other limits vary depending on service.	1	50	50	50	2				2	2																															001
H8634	003	0	1	04	01	H8634_003_0	7								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	008	0	1	04	01	H8634_008_0	6								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	010	0	1	04	01	H8634_010_0	7																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	012	0	1	04	01	H8634_012_0	7								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	019	0	1	04	01	H8634_019_0	6								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	022	0	1	04	01	H8634_022_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	023	0	1	04	01	H8634_023_0	9																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	025	0	1	04	01	H8634_025_0	8																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	026	0	1	04	01	H8634_026_0	6								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	027	0	1	04	01	H8634_027_0	7								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	028	0	1	04	01	H8634_028_0	7								2			2					2																																																																																																																		1	2	2	1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H8634	031	0	1	04	01	H8634_031_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8634	033	0	1	04	01	H8634_033_0	7																																																																																																																																		1	2	2	1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H8764	001	0	1	01	01	H8764_001_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	002	0	1	02	01	H8764_002_0	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	002	0	1	02	01	H8764_002_0	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Dentures are limited 1 every 60 months, denture adjustments are limited to 2 per arch per 12 months, denture repairs are limited to 2 per 60 months, rebase is limited to 1 per arch every 24 months, reline is limited to 1 per arch every 6 months.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	003	0	1	01	01	H8764_003_0	6																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	003	0	1	01	01	H8764_003_0	6																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	004	0	1	01	01	H8764_004_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8764	004	0	1	01	01	H8764_004_0	7																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	002
H8764	801	0	1	02	01	H8764_801_0	3																			1		1000.00	3		2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	3		2				2				2	2																3	2	2	3		2				2				2	2																															1	1					2					2		3	2	4	3		3		20	50	2				2	2	3	2	1	6	Endodontic therapy is limited to once per tooth per lifetime. Retreatment of a previous root canal is limited to once per tooth every 24 months.	1	50	50	50	2				2	2	3	2	1	6	Scaling and root planing in same quadrant: limited to once/24 months; Periodontal surgery in same quadrant limited to once/36 months.	1	50	50	50	2				2	2	3	2	1	6	Periodicity for Prosthodontics (D5110 - D5214) is once every 5 years.	1	50	50	50	2				2	2																3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	Every 5 years	1	50	50	50	2				2	2	3	2	1	6	1 per tooth per lifetime.	1	50	50	50	2				2	2																3	2	1	3		1	20	20	20	2				2	2	001
H8768	009	0	1	04	01	H8768_009_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	010	0	1	04	01	H8768_010_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	011	0	1	04	01	H8768_011_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	013	0	1	04	01	H8768_013_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	016	0	1	04	01	H8768_016_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	017	1	1	04	01	H8768_017_1	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	017	2	1	04	01	H8768_017_2	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	022	0	1	04	01	H8768_022_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	023	0	1	04	01	H8768_023_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	026	0	1	04	01	H8768_026_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	034	0	1	04	01	H8768_034_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	037	1	1	04	01	H8768_037_1	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	037	2	1	04	01	H8768_037_2	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	040	0	1	04	01	H8768_040_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	046	0	1	04	01	H8768_046_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	055	1	1	04	01	H8768_055_1	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	055	2	1	04	01	H8768_055_2	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	058	0	1	04	01	H8768_058_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	059	0	1	04	01	H8768_059_0	3	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	061	0	1	04	01	H8768_061_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	062	0	1	04	01	H8768_062_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8768	063	0	1	04	01	H8768_063_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
H8832	001	0	1	04	01	H8832_001_0	7	2	2	2		2	2		2	2	2	2	2			2	2			1	2	1000.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				2				2				1	2	3	1				2				2				1	2	3	1				2				2				1	2	3	1				2				2				1	2																															3	1				2				2				1	2	3	1				2				2				1	2																															001
H8832	002	0	1	04	01	H8832_002_0	7																			1	2	1500.00	3		2				2					2					2		3	1				2				2				1	2	3	1				2				2				1	2																3	1				2				2				1	2	3	1				2				2				1	2																1	1					2					2		3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				3		0	50	2				1	2	3	1				1	50	50	50	2				1	2																															3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																															001
H8849	001	0	1	02	01	H8849_001_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	001	0	1	02	01	H8849_001_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	001	0	1	02	01	H8849_001_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	003	0	1	02	01	H8849_003_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	003	0	1	02	01	H8849_003_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	003	0	1	02	01	H8849_003_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	005	0	1	02	01	H8849_005_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	005	0	1	02	01	H8849_005_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	005	0	1	02	01	H8849_005_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	006	0	1	02	01	H8849_006_0	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	006	0	1	02	01	H8849_006_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	006	0	1	02	01	H8849_006_0	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H8849	009	0	1	02	01	H8849_009_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H8849	009	0	1	02	01	H8849_009_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H8849	009	0	1	02	01	H8849_009_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9003	001	0	1	02	01	H9003_001_0	4																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		35	50	1	25.00	25.00	25.00	2	1	001
H9003	006	0	1	02	01	H9003_006_0	4																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		35	50	1	25.00	25.00	25.00	2	1	001
H9003	008	0	1	02	01	H9003_008_0	4																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	2	1	1		1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				1	50	50	50	2				1	2	3	1				1	50	50	50	2				1	2																3	1				3		35	50	1	25.00	25.00	25.00	1	2	001
H9003	009	0	1	02	01	H9003_009_0	4																			1		1250.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	3	1				2				1	0.00	0.00	0.00	2	2	1	1					2					1	50.00	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				1	50	50	50	2				2	1	3	1				1	50	50	50	2				2	1																3	1				3		35	50	1	25.00	25.00	25.00	2	1	001
H9047	013	0	2	01	01	H9047_013_0	9	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	013	0	2	01	01	H9047_013_0	9	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	033	0	1	01	01	H9047_033_0	8	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	033	0	1	01	01	H9047_033_0	8	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	035	0	1	02	01	H9047_035_0	8	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2																																														3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2																															3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	001
H9047	035	0	1	02	01	H9047_035_0	8	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	2				2				2	2	3	1				1	50	50	50	2				2	2																															3	1				2				2				2	2	2						2					2		3	1				3		30	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																															3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																3	1				3		0	50	2				2	2	002
H9047	037	0	1	01	01	H9047_037_0	10	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	037	0	1	01	01	H9047_037_0	10	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	054	0	1	01	01	H9047_054_0	10	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	054	0	1	01	01	H9047_054_0	10	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	063	0	1	01	01	H9047_063_0	11	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	063	0	1	01	01	H9047_063_0	11	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9047	064	0	1	01	01	H9047_064_0	10	2		2					2											2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2																																														3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2																															3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	001
H9047	064	0	1	01	01	H9047_064_0	10	2		2					2			2								2					2				2					2					2																	3	2	12	6	X-rays are covered as follows: bitewing series = 1 time per calendar year, full mouth or panoramic = 1 time every 5 years, single tooth as needed (up to 10 per calendar year).	3		0	20	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		0	20	2				2	2	2						2					2		3	1				3		30	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																															3	1				3		50	60	2				2	2	3	1				3		50	60	2				2	2																3	1				3		0	60	2				2	2	002
H9065	002	0	1	02	01	H9065_002_0	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	002	0	1	02	01	H9065_002_0	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	002	0	1	02	01	H9065_002_0	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9065	003	0	1	02	01	H9065_003_0	6																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	003	0	1	02	01	H9065_003_0	6																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	003	0	1	02	01	H9065_003_0	6																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9065	008	0	1	01	01	H9065_008_0	5																			1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9065	008	0	1	01	01	H9065_008_0	5																			1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9065	008	0	1	01	01	H9065_008_0	5																			1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9179	001	0	1	01	01	H9179_001_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	001	0	1	01	01	H9179_001_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9179	003	0	1	01	01	H9179_003_0	4	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9179	003	0	1	01	01	H9179_003_0	4	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9219	004	0	1	04	01	H9219_004_0	4	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9219	004	0	1	04	01	H9219_004_0	4	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9219	004	0	1	04	01	H9219_004_0	4	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	004	0	1	02	01	H9525_004_0	5	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	004	0	1	02	01	H9525_004_0	5	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	004	0	1	02	01	H9525_004_0	5	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	006	0	1	02	01	H9525_006_0	6	2	2			2														1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	006	0	1	02	01	H9525_006_0	6	2	2			2														1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	006	0	1	02	01	H9525_006_0	6	2	2			2														1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	011	0	1	02	01	H9525_011_0	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	011	0	1	02	01	H9525_011_0	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	011	0	1	02	01	H9525_011_0	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	1	1	02	01	H9525_013_1	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	1	1	02	01	H9525_013_1	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	1	1	02	01	H9525_013_1	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	2	1	02	01	H9525_013_2	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	2	1	02	01	H9525_013_2	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	2	1	02	01	H9525_013_2	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	3	1	02	01	H9525_013_3	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	3	1	02	01	H9525_013_3	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	3	1	02	01	H9525_013_3	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	4	1	02	01	H9525_013_4	5	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	4	1	02	01	H9525_013_4	5	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	4	1	02	01	H9525_013_4	5	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9525	013	5	1	02	01	H9525_013_5	6	2	2	2		2	2		2	2	2	2					2		2	1		1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
H9525	013	5	1	02	01	H9525_013_5	6	2	2	2		2	2		2	2	2	2	2				2		2	1		2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
H9525	013	5	1	02	01	H9525_013_5	6	2	2	2		2	2													1		500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
H9572	001	1	1	04	01	H9572_001_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	2	1	04	01	H9572_001_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	3	1	04	01	H9572_001_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	4	1	04	01	H9572_001_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	001	6	1	04	01	H9572_001_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	1	1	04	01	H9572_002_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	2	1	04	01	H9572_002_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	3	1	04	01	H9572_002_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	4	1	04	01	H9572_002_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	002	6	1	04	01	H9572_002_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	003	1	1	04	01	H9572_003_1	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	2	1	04	01	H9572_003_2	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	3	1	04	01	H9572_003_3	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	4	1	04	01	H9572_003_4	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	003	6	1	04	01	H9572_003_6	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, Consultation Exams	1	25	25	25	2				2	2	001
H9572	004	1	1	04	01	H9572_004_1	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	2	1	04	01	H9572_004_2	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	4	1	04	01	H9572_004_4	9								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	004	6	1	04	01	H9572_004_6	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	1	1	04	01	H9572_007_1	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	2	1	04	01	H9572_007_2	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	3	1	04	01	H9572_007_3	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	4	1	04	01	H9572_007_4	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	007	6	1	04	01	H9572_007_6	8								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	008	0	1	04	01	H9572_008_0	7																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	Fillings, Crowns, Crown Repairs. Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2	3	2	1	6	Root Canals - once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Deep Cleaning - periodontal scaling and root planing.Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2	3	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	1	25	25	25	2				2	2																3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	009	0	1	04	01	H9572_009_0	7								2	2		2																																																																																																																							1	2	2	1500.00	3		2					2		3	2	1	6	Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2																3	2	1	6	Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2																															3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9572	010	0	1	04	01	H9572_010_0	7																																																																																																																																		1	2	2	1500.00	3		2					2		3	2	1	6	Fillings, Crowns, Crown Repairs. Onlays - Includes metallic, porcelain/ceramic, or resin-based composite.	1	25	25	25	2				2	2	3	2	1	6	Root Canals - once per tooth per lifetime.	1	25	25	25	2				2	2	3	2	1	6	Deep Cleaning - periodontal scaling and root planing.Periodontal Surgery, full mouth debridement, delivery of antimicrobial agents. Dressing changes.	1	25	25	25	2				2	2	3	2	1	6	Dentures. Denture Adjustments, Repairs, Relines, Rebase.	1	25	25	25	2				2	2																3	2	1	6	Implants - placing implant. Prefabricated and custom abutments. Implant bridges and implant crowns. Implants Maintenance and repair.	1	25	25	25	2				2	2	3	2	1	6	Bridges and Repairs	1	25	25	25	2				2	2	3	2	1	6	Extractions, Brush Biopsies, and Oral Surgery which includes tooth reimplantation and stabilization, exposure and mobilization of unerupted tooth, and device to facilitate eruption.	1	25	25	25	2				2	2																3	2	1	6	Anesthesia, consultation exams.	1	25	25	25	2				2	2	001
H9686	008	0	1	01	01	H9686_008_0	10	2	2	2		2	2													1		1500.00	3		2				2					2					2		3	1				2				2				1	1	3	1				2				2				1	1																3	1				2				2				1	1	3	1				2				2				1	1																1	1					2					2		3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1	3	1				3		0	50	2				1	1	3	1				1	50	50	50	2				1	1																															3	1				1	50	50	50	2				1	1	3	1				1	50	50	50	2				1	1																															001
H9706	001	0	1	01	01	H9706_001_0	6																																																																																																																																		1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H9706	005	0	1	01	01	H9706_005_0	5																																																																																																																																		1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H9706	008	0	1	01	01	H9706_008_0	6																			2					2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	3		2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2																															1	2		1000.00	3		2					2		3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	001
H9706	009	0	1	01	01	H9706_009_0	6								2			2					2																																																																																																																		1	2		1000.00	3		2					2																	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																3	1				1	20	20	20	2				2	2	3	1				1	20	20	20	2				2	2																															001
H9808	010	0	1	04	01	H9808_010_0	6	2	2	2	2	2														2					2				2					2					2		3	2	2	3		2				2				2	2	3	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	3	2	1	6	See notes for specific coverage and frequencies	2				2				2	2	3	2	2	3		2				2				2	2																															1	2	2	1500.00	3		2					2		3	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2																3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	1	50	50	50	2				2	2	3	2	1	6	See notes for specific coverage and frequencies	3		20	50	2				2	2																3	2	1	6	See notes for specific coverage and frequencies	3		0	50	2				2	2	001
H9827	001	0	1	01	01	H9827_001_0	7	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9827	001	0	1	01	01	H9827_001_0	7	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9827	003	0	1	01	01	H9827_003_0	4	2			2			2	2	2	2	2					2		2	1		500.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency is unlimited, 1 per consecutive 36 months, 2 per consecutive 6 months, 2 per calendar year, or 8 per calendar year depending on service code.	2								2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 months or 1 per consecutive 60 months depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 per tooth per lifetime, or 2 per tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes unlimited, 2 per calendar year, 2 per consecutive 12 months, 1 per consecutive 36 months, 1 per quadrant per consecutive 24 or 36 months depending on service code.	1	50	50	50	2				2	2																																																													3	2	1	6	Frequency includes, unlimited, 1 per site per visit, per consecutive 36 months, or lifetime, 1 per tooth per lifetime, 1 biopsy per site per visit, or 1 per consecutive 36 months depending on code.	1	50	50	50	2				2	2																3	2	1	6	Frequency includes unlimited, 2 per calendar year, or 1 per consecutive 6 months depending on service code.	3		0	50	2				2	2	001
H9827	003	0	1	01	01	H9827_003_0	4	2			2			2	2	2	2	2					2		2	1		1000.00	3		2				2					1	001001	0.00	0.00	0.00	2																																3	2	1	6	Frequency includes unlimited, 2 per calendar year, 1 per consecutive 12, 24, 36, or 60 months, 2 per consecutive 6 or 12 months, 4 or 8 per calendar year, or 1 per visit depending on service code.	3		0	50					2	2																															3	2	1	6	Frequency includes unlimited, 1 per consecutive 6 or 60 months, 2 per consecutive 12 months, or 2 per calendar year depending on service code.	2								2	2	1	1					2					2		3	2	1	6	Frequency includes unlimited, 1 per consecutive 6, 12, or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency includes unlimited, 1 or 2 per tooth per lifetime, or 1 per primary or secondary tooth per lifetime depending on service code.	1	50	50	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2	3	2	1	6	Frequency includes 1 per consecutive 6, 12, or 60 months depending on service code.	1	50	50	50	2				2	2																															3	2	1	6	Frequency includes 1 per consecutive 6 or 60 months depending on service code.	3		0	50	2				2	2	3	2	1	6	Frequency varies depending on the service code. Please see note below.	1	50	50	50	2				2	2																3	2	1	6	Frequency varies depending on the service code. Please see note below.	2				1	0.00	0.00	0.00	2	2	002
H9834	001	0	1	01	01	H9834_001_0	5	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	003	0	1	01	01	H9834_003_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	004	0	1	01	01	H9834_004_0	3	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	006	0	1	01	01	H9834_006_0	4	1	1	1	1	1	1		1	1	1	1	1		1	1	1		1																																																																																																																																																																																																																																																																																			001
H9834	007	0	1	01	01	H9834_007_0	4	2	2			2														1		1000.00	3		2				2					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2																1	1					2					2		3	1				2				2				2	2	3	1				2				2				2	2	3	1				2				2				2	2	3	1				1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				2				2				2	2																3	1				2				2				2	2	001
R0110	005	0	1	31	11	R0110_005_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	008	0	1	31	11	R0110_008_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	012	0	1	31	11	R0110_012_0	2	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R0110	020	0	1	31	11	R0110_020_0	3	2	2	2	2	2		2	2	2									2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R2604	005	0	1	31	11	R2604_005_0	5	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R3444	009	0	1	31	11	R3444_009_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R3444	012	0	1	31	11	R3444_012_0	4	2	2	2		2	2	2	2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R4182	003	0	1	31	11	R4182_003_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R4182	004	0	1	31	11	R4182_004_0	4	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R5361	002	0	1	31	11	R5361_002_0	3	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R5941	013	0	1	31	11	R5941_013_0	6	2	2	2		2	2		2	2	2	2					2		2	1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	013	0	1	31	11	R5941_013_0	6	2	2	2		2	2		2	2	2	2	2				2		2	1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	013	0	1	31	11	R5941_013_0	6	2	2	2		2	2													1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R5941	014	0	1	31	11	R5941_014_0	6	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	014	0	1	31	11	R5941_014_0	6	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	014	0	1	31	11	R5941_014_0	6	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R5941	016	0	1	31	11	R5941_016_0	6	2	2			2														1	2	1000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				1	20	20	20	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																																													3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	001
R5941	016	0	1	31	11	R5941_016_0	6	2	2			2														1	2	2000.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																1	1					2					2		3	1				3		20	50	2				1	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2	3	1				1	50	50	50	2				2	2																																														3	2	1	6	Simple and Surgical Extractions (limited to once per tooth per year).	1	50	50	50	2				2	2																3	1				1	50	50	50	2				2	2	002
R5941	016	0	1	31	11	R5941_016_0	6	2	2			2														1	2	500.00	3		2				2					2					2		3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	1 full-mouth x-ray or panoramic x-ray per year and 1 bitewing series per calendar year and Up to 7 Periapical images per calendar year.	2				1	0.00	0.00	0.00	2	2																3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2																																																																																																																																																																																			003
R6694	006	0	1	31	11	R6694_006_0	3																																																																																																																																		1	2	2	1000.00	3		2					2		3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	20	20	20	2				2	2	3	2	4	6	four visits other	3		20	50	2				2	2	3	2	2	6	two visits other	1	50	50	50	2				2	2																															3	2	1	6	one visit other	1	50	50	50	2				2	2	3	2	1	6	one visit other	3		20	50	2				2	2																3	1				3		20	50	2				2	2	001
R6801	009	0	1	31	11	R6801_009_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R6801	012	0	1	31	11	R6801_012_0	4	2							2											1	2	1500.00	3		2				2					2					2		3	2	1	6	Periodicity varies by service ranging from 2 every year to 1 every 3 years.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per 60 floating months to 8 every year.	2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to 1 per floating day.	2				1	0.00	0.00	0.00	1	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	2	3		2				1	0.00	0.00	0.00	2	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 36 months to 2 per floating 12 months.	2				1	0.00	0.00	0.00	1	2	1	1					2					2		3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 4 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to 2 per year.	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per floating 60 months to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Recement or re-bond fixed partial denture: 1 per year Fixed partial denture repair: 1 per floating 24 months All other services: 1 every 5 years	1	50	50	50	2				1	2	3	2	1	6	Periodicity varies by service ranging from 1 per lifetime to unlimited.	1	50	50	50	2				1	2																3	2	1	6	Periodicity varies by service ranging from 1 per plan year to unlimited.	1	50	50	50	2				1	2	001
R7220	001	0	1	31	11	R7220_001_0	3	2	2	2	2	2		2	2	2		2							2	1	2	500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
R7220	002	0	1	31	11	R7220_002_0	2	2	2	2	2	2		2	2										2	1	2	1500.00	3		2				2					2					2		3	2	3	3		1	0	0	0	2				2	2	3	2	3	6	bitewing x-rays, intraoral x-rays 1 set(s)/yr, pano film/diag x-rays 1/5 yrs	1	0	0	0	2				2	2	3	2	1	1		1	0	0	0	2				2	2	3	2	2	3		1	0	0	0	2				2	2																3	2	4	3		1	0	0	0	2				2	2	1	1					2					2		3	2	3	6	core buildup/prefab post/core, crown 1/tooth/lifetime, crown recement 1/5 yrs, filling unl/yr	3		0	50	2				1	2	3	2	2	6	root canal, root canal retreat 1/tooth/lifetime	1	50	50	50	2				1	2	3	2	2	1		1	0	0	0	2				1	2	3	2	7	6	comp dentures, part dentures 1/5 yrs, denture adj, rebase, reline, repair, tissue cond 1/yr	1	50	50	50	2				1	2																															3	2	4	6	bridge recement, bridges-pontic 1/5 yrs, bridges-crown 2/5 yrs	1	50	50	50	2				1	2	3	2	2	6	extractions unl/yr, oral surg 2/yr	3		0	50	2				1	2																3	2	3	6	emerg treatment for pain 2/yr, necessary anesthesia with covered service  as needed with covered codes/yr, occlusal adj 1/3 yrs	3		0	50	2				1	2	001
